Topographical and cell type-specific connectivity of rostral and caudal forelimb corticospinal neuron populations

Corticospinal neurons (CSNs) synapse directly on spinal neurons, a diverse assortment of cells with unique structural and functional properties necessary for body movements. CSNs modulating forelimb behavior fractionate into caudal forelimb area (CFA) and rostral forelimb area (RFA) motor cortical populations. Despite their prominence, the full diversity of spinal neurons targeted by CFA and RFA CSNs is uncharted. Here, we use anatomical and RNA sequencing methods to show that CSNs synapse onto a remarkably selective group of spinal cell types, favoring inhibitory populations that regulate motoneuron activity and gate sensory feedback. CFA and RFA CSNs target similar spinal neuron types, with notable exceptions that suggest that these populations differ in how they influence behavior. Finally, axon collaterals of CFA and RFA CSNs target similar brain regions yet receive highly divergent inputs. These results detail the rules of CSN connectivity throughout the brain and spinal cord for two regions critical for forelimb behavior.

Assessment of a novel electrochemically deposited smart bioactive trabecular coating (SBTC®): a randomized controlled clinical trial

OBJECTIVES

A randomized controlled clinical trial of dental implants was conducted to compare the clinical properties of a novel electrochemically deposited calcium phosphate coating to those of a common marketed surface treatment.

MATERIAL AND METHODS

Forty implants of the same brand and type were placed in 20 fully edentulous participants requiring mandibular implantation. The two study groups were defined by the surface treatment of the implants. 20 implants in the control group were coated via a commercial electrochemical surface treatment that forms a mixture of brushite and hydroxyapatite, while the remaining 20 in the test group were coated with a novel electrochemical Smart Bioactive Trabecular Coating (SBTC®). A split-mouth design was employed, with each participants receiving one control implant in one mandibular side and a test implant in the other. To mitigate potential operator-handedness bias, control and test implants were randomly assigned to mandibular sides. All cases underwent digital planning, implant placement with a static surgical guide, and participants received locator-anchored full-arch dentures. The primary outcome was implant stability (measured using Osstell ISQ) assessed at insertion, loading, and then 3 months, 9 months, and 2 years post-insertion. The secondary outcome was bone level change (in millimeters) over the 2-year observation period. Oral health-related quality of life (OHRQL) was monitored using the OHIP-14 questionnaire. Complications and adverse events were recorded.

RESULTS

Successful osseointegration and implant stability were achieved in all cases, allowing loading. ISQ values steadily increased throughout the observation period. While no significant differences were observed between the SBTC® and control coatings, the test group exhibited a higher ISQ gain. Bone resorption was somewhat lower in the SBTC® but not significantly so. Patients' OHRQL significantly improved after denture delivery and remained stable throughout the follow-up. No complications or adverse events were observed.

CONCLUSIONS

Based on the study results, we conclude that the new surface treatment is a safe alternative to the widely used control surface, demonstrating similar osseointegrative properties and time-dependent bone level changes. Further research may explore the broader implications of these findings.

TRIAL REGISTRATION

The study is registered on clinicaltrials.gov under the identifier ID: NCT06034171.

Radiofrequency for chronic lumbosacral and cervical pain: Results of a consensus study using the RAND/UCLA appropriateness method

BACKGROUND

Despite the routine use of radiofrequency (RF) for the treatment of chronic pain in the lumbosacral and cervical region, there remains uncertainty on the most appropriate patient selection criteria. This study aimed to develop appropriateness criteria for RF in relation to relevant patient characteristics, considering RF ablation (RFA) for the treatment of chronic axial pain and pulsed RF (PRF) for the treatment of chronic radicular pain.

METHODS

The RAND/UCLA Appropriateness Method (RUAM) was used to explore the opinions of a multidisciplinary European panel on the appropriateness of RFA and PRF for a variety of clinical scenarios. Depending on the type of pain (axial or radicular), the expert panel rated the appropriateness of RFA and PRF for a total of 219 clinical scenarios.

RESULTS

For axial pain in the lumbosacral or cervical region, appropriateness of RFA was determined by the dominant pain trigger and location of tenderness on palpation with higher appropriateness scores if these variables were suggestive of the diagnosis of facet or sacroiliac joint pain. Although the opinions on the appropriateness of PRF for lumbosacral and cervical radicular pain were fairly dispersed, there was agreement that PRF is an appropriate option for well-selected patients with radicular pain due to herniated disc or foraminal stenosis, particularly in the absence of motor deficits. The panel outcomes were embedded in an educational e-health tool that also covers the psychosocial aspects of chronic pain, providing integrated recommendations on the appropriate use of (P)RF interventions for the treatment of chronic axial and radicular pain in the lumbosacral and cervical region.

CONCLUSIONS

A multidisciplinary European expert panel established patient-specific recommendations that may support the (pre)selection of patients with chronic axial and radicular pain in the lumbosacral and cervical region for either RFA or PRF (accessible via https://rftool.org). Future studies should validate these recommendations by determining their predictive value for the outcomes of (P)RF interventions.

Endoportal Radiofrequency Ablation and Stent Placement in Patients with Portal Vein Tumor Thrombosis from Hepatocellular Carcinoma: A Study on Feasibility and Safety

Background: Hepatocellular carcinoma (HCC) is the most common type of liver cancer, with 10-40% of cases involving portal vein tumor thrombosis (PVTT), leading to poor outcomes and a short survival. The effectiveness of PVTT treatment in patients with HCC is still controversial. Methods: This prospective dual-center study cohort comprised 60 patients with HCC and PVTT who underwent PVR-EPRFA-ST using a novel intravascular radiofrequency system followed by vascular stent placement across the PVTT stenosed segment under fluoroscopy guidance. Results: PVR-EPRFA-ST was technically and clinically successful in 54/60 (90%) and 37/54 (68.5%) patients, respectively. The mean tumor size, PVTT length, post-ablation luminal diameter, and median duration of the recanalized PV patency were 8.6 ± 3.4 cm, 4.1 ± 2.1 cm, 10.3 ± 1.8 mm, and 13.4 months. Higher technical and clinical success rates were associated with a longer survival (177 ± 17.3 days, HR: 0.3, 95%CI 0.12-0.71, p = 0.04; and 233 ± 18.3 days, HR: 0.14, 0.07-0.27, p < 0.001). A shorter survival was associated with Child-Pugh C (HR: 2.7, p = 0.04), multiple tumors (HR: 1.81, p = 0.03), and PVTT length (HR: 1.16, p = 0.04). Conclusions: PVR-EPRFA-ST was feasible and effective for the treatment of selected patients with PVTT, especially in patients with Child-Pugh A/B, single tumors, or a shorter PVTT length.

Recurrent gastric antral vascular ectasia: a single center experience

Introduction

Gastric antral vascular ectasia (GAVE) is a rare cause of chronic or acute gastrointestinal bleeding. This condition accounts for ∼4% of upper gastrointestinal bleeding cases. This disease is often associated with systemic diseases, such as liver cirrhosis, chronic kidney failure, autoimmune conditions, diabetes mellitus, hypothyroidism, and cardiovascular diseases. However, its etiopathogenesis remains controversial.

Materials and method

We retrospectively reviewed the cases of GAVE treated at our digestive surgery unit. A total of nine patients were identified with a male/female ratio of 1.25:1 and an average age of 75.51 years (SD ± 9.85). All patients underwent endoscopic argon plasma coagulation (APC) treatment. At the time of the review, data on eight patients were available after 36 months of follow-up.

Results

APC appears to be safe and effective for hemostasis of bleeding vascular ectasia. Only one (11.1%) patient required surgical intervention due to hemodynamic instability after multiple unsuccessful endoscopic treatments. No intraoperative and postoperative complication or bleeding relapse was experienced.

Discussion

Based on our findings, we concluded that endoscopic APC is technically simple, but requires multiple re-interventions due to the incidence of relapses. Furthermore, larger randomized studies should be conducted to assess the role of elective surgery as the first intervention in stable patients with severe pathology and the timing of surgery after failed endoscopic treatment.

Pancreatic cancer with synchronous peritoneal and hepatic metastases: A case report

Introduction and importance: There is evidence that patients with limited peritoneal carcinomatosis of pancreatic cancer or those with low burden of hepatic metastases are amenable to surgical resection. A case report of a patient with cancer of the pancreatic tail and synchronous peritoneal and hepatic metastases is presented.

CASE PRESENTATION

A male patient, 66 years old, underwent cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) and radio-frequency ablation (RFA) for synchronous hepatic metastases simultaneously to distal pancreatectomy for adenocarcinoma of the pancreas. Adjuvant chemotherapy followed the R0 surgery. The patient remained disease free for 18 months, developed liver recurrence and died 28 months after the initial operation.

DISCUSSION

CRS plus HIPEC with synchronous ablation or resection of hepatic metastases may be used for the treatment of pancreatic cancer with synchronous peritoneal and hepatic metastases in highly selected patients.

CONCLUSION

Further studies are needed to confirm whether patients with synchronous peritoneal and hepatic metastases are offered survival benefit from complex surgical intervention (CRS plus HIPEC combined with hepatic resection or RFA).

Endoscopic treatment for early duodenal papillary carcinoma: long-term outcomes

BACKGROUND AND AIM

This study aims to determine whether endoscopic papillectomy (EP) is a safe and effective treatment for early duodenal papillary carcinoma with long-term follow-up.

METHODS

From June 2012 to September 2022, 48 patients with early duodenal papilloma carcinoma who received endoscopic treatment were included. The histological types, percentage of complete resections, postoperative residuals, adverse events, and recurrences were evaluated.

RESULTS

EP was successful in all patients; 46 were lumped, and two were fragmented, with a 95.8% intact removal rate (46/48). The preoperative biopsy pathological positive rate was 70.8% (34/48). The incidence of early postoperative adverse events (within 1 month after EP) were 16.7% (8/48), including four cases of acute pancreatitis, three cases of delayed bleeding, and one case of acute cholangitis. In addition, 4.2% (2/48) of the late adverse events were bile duct stenosis. After 6 months, the postoperative residual rate was 0%. The median time to recurrence was 17.5 months, and the postoperative recurrence rate was 16.7% (8/48) in patients treated with radiofrequency ablation. The median progression-free survival was 18.6 months (95% CI, 12.1-25.1), and the median overall survival was 121.5 months (95% CI, 105.6-120.9).

CONCLUSIONS

EP is a safe and efficient alternative therapy for early duodenal papillary carcinoma. Endoscopic follow-up and treatment are essential because of the potential for recurrence.

Transoral percutaneous radiofrequency ablation with a steerable needle and cementoplasty under CBCT and infrared augmented reality navigation system guidance for the treatment of a C1 solitary plasmacytoma: A case report

We report a case of a 40-year-old female with a solitary plasmacytoma of the right transverse apophysis of C1 who underwent combined transoral ablation using a curved steerable needle and cementoplasty under CBCT and infra-red augmented reality navigation system. An imaging work-up revealed an osteolytic lesion determining partial collapse of the right lateral mass of C1 and involving the vertebral foramen. After a biopsy, that revealed a solid tissue consistent with plasmacytoma, it was decided to proceed with radiation therapy. Subsequent PET-CT restaging scans showed residual tumors treated with a transoral percutaneous approach, combining ablation and cementoplasty. This report evaluates the benefits of this combined procedure and the transoral approach, focusing on the advantages of steerable devices and navigation systems.

Radiofrequency ablation vs. hepatectomy for liver metastases from gastrointestinal stromal tumors

For patients with gastrointestinal stromal tumors (GISTs) and liver metastases, there is still debate about whether radiofrequency ablation (RFA) or hepatectomy is preferable. The present study aimed to compare the clinical outcomes of RFA with hepatectomy in patients with GISTs and liver metastases. The present retrospective study consisted of a cohort of 43 patients who had been diagnosed with liver metastases from GISTs between January 2010 and December 2022. The study included 18 patients who received RFA combined with tyrosine kinase inhibitor (TKI) therapy (RFA group) and 25 patients who underwent hepatectomy combined with TKI therapy (hepatectomy group). For the patients with liver metastases, the progression-free survival (PFS) rates at 1, 3 and 5 years were 66.5, 38.2 and 33.9%, respectively. Notably, patients in the hepatectomy group exhibited significantly improved PFS times compared with those in the RFA group (median PFS, 42.7 months vs. 14.3 months; P=0.034). Furthermore, the time to imatinib treatment failure (TTF) was notably improved in the hepatectomy group compared with that in the RFA group, and this difference was statistically significant (median TTF, 71.1 vs. 38.0 months; P=0.041). However, the overall survival (OS) times of patients who received RFA and those who had hepatectomy did not differ significantly (median OS, not reached vs. not reached, P=0.120). There was no statistically significant distinction in PFS and TTF between patients who underwent hepatectomy combined with postoperative TKI and those who underwent hepatectomy combined with perioperative TKI (median PFS, 29.5 vs. not reached; P=0.520; median TTF, 66.4 months vs. 71.1 months; P=0.430). The univariate and multivariate analyses consistently identified the sole prognostic factor affecting PFS as hepatectomy combined with TKI therapy (hazard ratio, 0.379; 95% CI, 0.159-0.899; P=0.028). In conclusion, hepatectomy combined with TKI therapy improved prognosis for patients with liver metastases to a greater extent than RFA combined with TKI therapy. For this type of patient, hepatectomy may be a preferable option.

Threatment Strategies for Recurrent Hepatocellular Carcinoma Patients: Ablation and its Combination Patterns

With the development of guidance technology and ablation equipment, ablative procedures have emerged as important loco-regional alternatives to surgical resection for recurrent hepatocellular carcinoma (rHCC) patients. Currently, ablation modalities used in clinical practice mainly include radiofrequency ablation (RFA), microwave ablation (MWA), laser ablation (LA), cryoablation (CRA), high-intensity focused ultrasound (HIFU), and irreversible electroporation (IRE). Accumulated comparative data of ablation versus surgical resection reveal noninferior responses and outcomes but superior adverse effects. Moreover, studies demonstrate that ablation may serve as an excellent procedure for rHCC given its exact minimal invasiveness and immune modulation. We focus on the current status of ablation in clinical practice for rHCC and discuss new research in the field, including ablation combined with these other modalities, such as targeted therapy and immunotherapy.

Overview of Thyroid and Parathyroid Disease: The Otolaryngology Perspective

The management of thyroid and parathyroid pathology varies widely, with unifying goals of symptomatic control and mitigating patient morbidity. In general, surgery is indicated when addressing malignancy or when medical management is insufficient. Over the last few decades, treatment paradigms for patients with head and neck endocrine disease have shifted significantly as our understanding of disease processes has expanded and with the advent of numerous relevant technologies. Here we provide a general overview of thyroid and parathyroid disease that may be managed by the otolaryngologist, with attention to emerging strategies in diagnosis and treatment.

Comparative efficacies and safeties of cylindrical interstitial laser ablation and radiofrequency ablation on swine pancreas

Laser ablation (LA) has been evaluated for the minimally invasive thermal treatment of various cancers, but conventional unidirectional endoscopic ultrasound (EUS)-guided LA has limitations. Therefore, we developed a cylindrical laser diffuser to overcome the limitations of unidirectional EUS-guided LA. The purpose of this study was to compare the efficacies and safeties of EUS-guided LA using a novel cylindrical laser diffuser and radiofrequency ablation (RFA) in vivo in swine pancreas. EUS-guided RFA (15 W, 30 s, 450 J) and cylindrical interstitial LA (CILA) (5 W, 90 s, 450 J) were applied to normal pancreatic tissue in six anesthetized pigs (three per group). Laboratory tests were performed at baseline, immediately after ablation (day 0), and 2 days after procedures (day 2). Two days after procedures, all pigs were sacrificed, and histopathological safety and efficacy assessments were performed. Technically, EUS-guided RFA and CILA were performed successfully in all cases. No major complications, including perforation or acute pancreatitis, occurred during the experiment in either group. All animals remained in excellent condition throughout the experimental period, and laboratory tests provided no evidence of a major complication. Average necrotic volumes in the RFA and CILA groups were 424.2 mm3 and 3747.4 mm3, respectively, and average necrotic volume was significantly larger in CILA group (p < 0.001). EUS-guided RFA and CILA had acceptable safety profiles in the normal swine pancreas model. Our findings indicate EUS-guided CILA has potential for the effective local treatment of pancreatic cancer as an alternative to EUS-guided RFA.

Value and limitations of postoperative duplex scans after endovenous thermal ablation

BACKGROUND

Endovenous thermal ablation (EVTA) of the lower extremity veins has risen to become the main treatment modality for symptomatic venous reflux disease. One of the main reported side effects of EVTA is recanalization. As of today, there is no clear protocol as to when follow-up duplex ultrasound scans should be performed. However, the standard for postoperative duplex after truncal ablation is within 1 week of the procedure. Our aim is to try to find whether there is a particular time period when postoperative duplex ultrasound scans should be performed to allow us to best diagnose recanalization.

METHODS

We retrospectively analyzed 9799 procedures in 3237 patients with chronic venous insufficiency owing to great, small, and anterior accessory saphenous vein insufficiency from 2012 to 2018. We excluded 466 perforator veins. All 9799 procedures were performed using EVTA in patients who failed to respond to conservative management initially. Postoperative duplex ultrasound scans were performed within 1 week (3-7 days postoperatively). We defined a successful obliteration as lack of color flow on postoperative scan. We defined symptomatic recanalization as presence of reflux on duplex ultrasound examination in the targeted vessel at follow-up with symptom recurrence. Follow-ups were performed every 3 months in the first year and every 6 months thereafter.

RESULTS

Patient ages ranged from 15 to 99 years. The median patient age at the time of the procedures was 63 years (interquartile range [IQR], 51-73 years). The median overall follow-up was 25 months (IQR, 4-56 months). The Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) class of all the procedures were: C1, 21; C2, 208; C3, 3585; C4, 4680; C5, 188; and C6, 1117. There were 145 redo procedures performed after symptomatic recanalization was diagnosed in patients. CEAP class of the redo patients were: C1, 0; C2, 2; C3, 49; C4, 70; C5, 5; and C6, 19.

CONCLUSIONS

Most patients underwent a redo procedure performed within the first year after the initial procedure. Conversely, there was great variability as to when redo procedures were performed. Because there is no defined pattern as to when these symptomatic occurrences arise, it may not be required to perform postoperative duplex ultrasound scans after EVTA routinely, but instead when a patient comes back with symptoms such as swelling.

Radiofrequency ablation for the treatment of multifocal or large-scale high-grade intraepithelial neoplasia of the esophagus: A safe & effective approach

doi: https://doi.org/10.12669/pjms.40.1.8927 How to cite this: Yang Y, Liu L, Zhu J. Radiofrequency ablation for the treatment of multifocal or large-scale high-grade intraepithelial neoplasia of the esophagus: A safe and effective approach. Pak J Med Sci. 2024;40(1):---------. doi: https://doi.org/10.12669/pjms.40.1.8927

Radiofrequency ablation of the occipital nerves for treatment of neuralgias and headache

OBJECTIVE

The purpose of this study was to retrospectively assess the efficacy of radiofrequency ablation (RFA) therapy as a treatment for occipital neuralgias and headaches at health clinics in the United States between January 1, 2015 and June 20, 2022. We hypothesize that RFA is a minimally invasive treatment that provides significant pain relief long-term for occipital neuralgias and associated headaches.

METHODS

This retrospective analysis studies data collected from 277 occipital nerve RFA patients who had adequate pre-procedure and post-procedure follow-up for data analysis. Data collected includes the patient's age, biological sex, BMI, headache diagnosis, pre-procedure, and post-procedure pain score using the visual analog scale (VAS), subjective percent improvement in symptom(s), and duration of symptom relief. Statistical analysis used SPSS software, version 26 (IBM), using a paired t-test to assess the significance between pre and post-occipital RFA therapy pain scores. p-values were significant if found to be ≤0.05.

RESULTS

The mean pre-procedure pain score before RFA therapy for patients who completed at least 6 months of follow-up was 5.57 (SD = 1.87) and the mean post-procedure pain score after RFA therapy was 2.39 (SD = 2.42). The improvement in pain scores between pre-procedure and post-procedure was statistically significant with a p-value < 0.001. The mean patient-reported percent improvement in pain following RFA therapy was 63.53% (SD = 36.37). The mean duration of pain improvement was 253.9 days after the initiation of therapy (SD = 300.5). When excluding patients who did not have any relief following their RFA procedure, the average pre-procedure pain score was 5.54 (SD = 1.81) and post-procedure pain score was 1.71 (SD = 1.81) with a p-value < 0.001.

CONCLUSION

This study demonstrates the minimally invasive, safe, and effective treatment of RFA in patients with refractory occipital neuralgias and headaches. Additional studies are necessary to illuminate ideal patient characteristics for RFA treatment and the potential for procedural complications and long-term side effects associated with occipital nerve RFA therapy.

Diaphragmatic Liver Herniation after Radiofrequency Ablation of a Secondary Liver Tumor

Radiofrequency thermal ablation (RFA) is widely used and has been accepted for the treatment of unresectable tumors. The leading technique that is used is percutaneous RFA under CT or US guidance. Multicenter surveys report acceptable morbidity and mortality rates for RFA. The mortality rate ranges from 0.1% to 0.5%, the major complication rate ranges from 2% to 3%. Diaphragmatic injury is a rare complication and it is described after RFA of subdiaphragmatic tumors. Most of them are without clinical importance. There are some case reports about diaphragmatic herniation of the intestine into the pleural cavity. We present a case of diaphragmatic perforation resulting in the herniation of the liver into the pleural cavity. A thoracotomy was performed, the liver was lowered back into the peritoneal cavity and the perforation was closed with mesh.

Ablation margin quantification after thermal ablation of malignant liver tumors: How to optimize the procedure? A systematic review of the available evidence

Introduction

To minimize the risk of local tumor progression after thermal ablation of liver malignancies, complete tumor ablation with sufficient ablation margins is a prerequisite. This has resulted in ablation margin quantification to become a rapidly evolving field. The aim of this systematic review is to give an overview of the available literature with respect to clinical studies and technical aspects potentially influencing the interpretation and evaluation of ablation margins.

Methods

The Medline database was reviewed for studies on radiofrequency and microwave ablation of liver cancer, ablation margins, image processing and tissue shrinkage. Studies included in this systematic review were analyzed for qualitative and quantitative assessment methods of ablation margins, segmentation and co-registration methods, and the potential influence of tissue shrinkage occurring during thermal ablation.

Results

75 articles were included of which 58 were clinical studies. In most clinical studies the aimed minimal ablation margin (MAM) was ≥ 5 mm. In 10/31 studies, MAM quantification was performed in 3D rather than in three orthogonal image planes. Segmentations were performed either semi-automatically or manually. Rigid and non-rigid co-registration algorithms were used about as often. Tissue shrinkage rates ranged from 7% to 74%.

Conclusions

There is a high variability in ablation margin quantification methods. Prospectively obtained data and a validated robust workflow are needed to better understand the clinical value. Interpretation of quantified ablation margins may be influenced by tissue shrinkage, as this may cause underestimation.

Primary versus Salvage Liver Transplantation after Curative-Intent Resection or Radiofrequency Ablation for Hepatocellular Carcinoma: Long-Term Oncological Outcomes

Liver transplantation for hepatocellular carcinoma (HCC) may be performed ab initio, primary liver transplantation (PLT), or for HCC recurrence after previous treatments such as liver resection (LR) or radiofrequency ablation (RFA), salvage liver transplantation (SLT). The aim of this study was to evaluate the oncological outcomes of SLT vs. PLT. For this, a retrospective study was carried out on patients undergoing liver transplantation for HCC. The outcomes of PLT were compared with those of SLT. The primary outcome was disease-free survival (DFS). The secondary outcomes included overall survival (OS), cancer-specific survival (CSS), and major postoperative complications. A sub-analysis of SLT-LR and SLT-RFA was also performed. In total, 141 patients were included: 96 underwent PLT and 45 SLT. Among the SLT group, 25 patients had undergone previous LR while 20 had had RFA. There were no differences in the major postoperative complications. Unadjusted DFS was significantly longer in the PLT group (p = 0.02), as were OS (p = 0.025) and CSS (p = 0.001). There was no difference in DFS between PLT and SLT-LR groups, while a significant difference was found between the PLT and SLT-RFA groups (p = 0.035). Nonetheless, DFS was no different between the SLT-LR and SLT-RFA groups. PLT appears to offer superior long-term oncological outcomes to SLT. Both SLT-LR and SLT-RFA offer acceptable OS and CSS. Further prospective studies are needed to confirm these results, but the re-direction of grafts and transplant philosophy towards PLT rather than SLT may need to be considered.

Survival after radiofrequency ablation and/or chemotherapy for lung cancer and pulmonary metastases: a systematic review and meta-analysis

Background

Radiofrequency ablation (RFA) and chemotherapy are used to treat lung cancer or pulmonary metastases, but no direct comparison of overall survival (OS) has been published. The present study aimed to assess the OS of RFA and/or chemotherapy in patients with lung cancer or pulmonary metastases who were not candidates for surgical resection.

Methods

To identify relevant studies, the following databases were electronically searched from their inception to 31 March 2023: PubMed, Embase, Web of Science, Cochrane Library, Scopus, Ovid, ScienceDirect, SinoMed, China National Knowledge Infrastructure Database, Chongqing VIP Chinese Science and Technology Periodical Database, Wanfang Database, LILACS, ClinicalTrials.gov, and Chictr.org. Manual retrieval was also conducted. We used published hazard ratios (HRs) if available or estimates from other survival data.

Results

A total of 1,387 participants from 14 trials were included in the final analysis. Patients treated with RFA combined with chemotherapy significantly improved OS compared with those treated with chemotherapy alone [HR 0.50, 95% confidence interval (CI) 0.41-0.61; p < 0.00001], with an absolute difference at 12 months of 29.6% (95% CI 23.7-35.5), at 24 months of 19.2% (95% CI 10.1-28.2), and at 36 months of 22.9% (95% CI 12.0-33.7). No statistically significant difference was observed in the subgroups of case type, cancer type, chemotherapy drugs, and tumor size. The HR for OS with RFA plus chemotherapy vs. RFA alone was 0.53 (95% CI 0.41-0.70; p < 0.00001), corresponding to a 27.1% (95% CI 18.3-35.8), 31.0% (95% CI 19.9-41.9), and 24.9% (95% CI 15.0-34.7) absolute difference in survival at 12 months, 24 months, and 36 months, respectively. Subgroup analysis by geographic region and TNM stage showed that RFA combined with chemotherapy still significantly improved OS compared to RFA. The HR of RFA vs. chemotherapy was 0.98 (95% CI 0.60-1.60; p = 0.94), with an absolute difference at 12 months of 1.4% (95% CI -19.2 to 22.1), at 24 months of 7.8% (95% CI -11.3 to 26.8), and at 36 months of 0.3% (95% CI -13.2 to 13.8). The overall indirect comparison of OS for RFA vs. chemotherapy was 0.95 (95% CI 0.72-1.26; p = 0.74). Data on progression-free survival were not sufficiently reported.

Conclusion

RFA combined with chemotherapy might be a better treatment option for patients with lung cancer or pulmonary metastases than chemotherapy alone or RFA alone. The comparison between RFA and/or chemotherapy remains to be specifically tested.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=335032, identifier CRD42022335032.

Facets of facet joint interventions

Facet joint (FJ) disease is a common cause of axial low back pain with many minimally invasive image-guided treatment options. This article discusses fluoroscopic and CT-guided intraarticular FJ injections, medial branch (MB) radiofrequency ablation (RFA), and lumbar facet synovial cyst (LFSC) aspiration, rupture, or fenestration. Additionally, the article will highlight medial branch blocks (MBBs) utilized to diagnose facet-mediated pain and to predict outcomes to RFA.

Salvage Hepatectomy for Recurrent Hepatocellular Carcinoma after Radiofrequency Ablation: A Retrospective Cohort Study with Propensity Score-Matched Analysis

BACKGROUND AND OBJECTIVES

Although radiofrequency ablation (RFA) is a well-established locoregional treatment modality for hepatocellular carcinoma (HCC), the optimal strategy to handle local recurrence after ablation is still debated. This study aims to investigate the role of salvage hepatectomy (SH) as a rescue therapy for recurrent HCC after RFA.

MATERIALS AND METHODS

Between January 2004 and December 2020, 1161 patients were subject to surgical resection for HCC. Among them, 47 patients who underwent SH for local recurrence after ablation were retrospectively analyzed and compared to a propensity score-matched group of controls (n = 47) who received primary hepatectomy (PH). Short-term and long-term outcomes were analyzed between the two groups.

RESULTS

After matching, operation time, intraoperative blood loss, postoperative hospital stay, and postoperative morbidity rates showed no statistically significant difference. Tumors in the SH group were associated with poor differentiation (SH 9 (19.1%) vs. PH 1 (2.1%), p < 0.001). The 5-year disease-free survival rates (31.6% vs. 73.4%, p < 0.001) and overall survival rates (80.3% vs. 94.2%, p = 0.047) were significantly lower in the SH group. In multivariable analysis, less extensive resection compared to the initial plan (hazard ratio (HR) 4.68, p = 0.024), higher grade (HR 5.38, P < 0.001), negative but close (<0.1 cm) resection margin (HR 22.14, p = 0.007), and R1 resection (HR 3.13, p = 0.006) were significant predictors for recurrence.

CONCLUSIONS

SH for recurrent tumors after ablation showed safety and effectiveness equivalent to primary resection. As recurrent tumors show a higher grade and more aggressive behavior, more extensive resections with wide surgical margins are necessary to prevent recurrence.

Influence of Implant Macro-Design, -Length, and -Diameter on Primary Implant Stability Depending on Different Bone Qualities Using Standard Drilling Protocols-An In Vitro Analysis

(1) Background: Primary implant stability is vital for successful implant therapy. This study explores the influence of implant shape, length, and diameter on primary stability in different bone qualities. (2) Methods: Three implant systems (two parallel-walled and one tapered) with various lengths and diameters were inserted into polyurethane foam blocks of different densities (35, 25, 15, and 10 PCF) using standard drilling protocols. Primary stability was assessed through insertion torque (IT) and resonance frequency analysis (RFA). Optimal ranges were defined for IT (25 to 50 Ncm) and RFA (ISQ 60 to 80). A comparison of implant groups was conducted to determine adherence to the optimal ranges. (3) Results: Implant macro-design, -length, and -diameter and bone block density significantly influenced IT and RFA. Optimal IT was observed in 8/40 and 9/40 groups for the parallel-walled implants, while the tapered implant achieved optimal IT in 13/40 groups (within a 25-50 Ncm range). Implant diameter strongly impacted primary stability, with sufficient stability achieved in only one-third of cases despite the tapered implant's superiority. (4) Conclusions: The findings highlight the need to adapt the drilling protocol based on diverse bone qualities in clinical practice. Further investigations should explore the impact of these adapted protocols on implant outcomes.

Can Thyroid Nodules be Managed with Radiofrequency Ablation?

Radiofrequency ablation (RFA) is an established and growing minimally-invasive technique with an impressive safety profile used to manage thyroid nodules. Beyond shorter operative and recovery times, the main advantages of RFA include the lack of an incisional scar as well as maximizing the potential for maintenance of normal thyroid function. RFA can significantly reduce nodular volume, achieving rates of 60% to 95% in a breadth of thyroid disease, including benign nodules, primary carcinomas, and recurrent malignancies. Thorough patient counselling is imperative for RFA candidates, including a discussant of complications, nodule regrowth, and the potential for a subsequent ablation session.

A Systematic Review Network Meta-Analysis and Meta-Regression on Surgical and Endovenous Interventions for the Treatment of Lower Limb Venous Ulcer Disease

BACKGROUND

Venous leg ulcer (VLU) disease constitutes the most severe form of chronic venous insufficiency. We performed a network meta-analysis and meta-regression to investigate the efficacy and safety of the various available interventions in the treatment of VLU.

METHODS

We conducted a systematic research corresponding to the instructions by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for studies reporting on surgical or endovenous interventions for the treatment of VLU. Following data extraction, we performed a Bayesian network meta-analysis and meta-regression. Primary endpoints included VLU healing and recurrence. The secondary endpoint was postintervention complications.

RESULTS

Seventeen studies evaluating the impact of compression monotherapy, radiofrequency ablation (RFA), endovenous laser ablation (EVLA), sclerotherapy, and saphenous vein surgery on VLU treatment, consisting of 2156 patients (2186 VLU) were included. When compared to compression monotherapy, RFA was the only treatment displaying a statistically-significant impact on ulcer healing, odds ratio (OR) 5.80 (95% credibility interval (CI): 1.08-35.07), while EVLA, RR 0.06 (95% CI: 0.00-0.57), sclerotherapy, RR 0.07 (95% CI: 0.00-0.68) and RFA, RR 0.12 (95% CI: 0.01-0.91) were the 3 interventions reducing VLU recurrence. EVLA (SUCRA, 69.65) ranked as the most efficient intervention concerning ulcer recurrence reduction. Regarding postintervention complications, EVLA was the only intervention displaying a statistically-significant increased risk compared to compression monotherapy, RR 14.3 (95% CI: 2.03-172.56). Meta-regression analysis exploring the impact of perforator treatment on VLU failed to predict healing, β = -0.27 (95% CI: -2.55 to 1.85), recurrence, β = -0.02 (95% CI: -2.96 to 2.75) and complication outcomes, β = -0.089 (95% CI: -3.13 to 2.85). During sensitivity analysis, RFA and sclerotherapy failed to sustain their effects on ulcer healing and ulcer recurrence, respectively. In addition, sclerotherapy displayed statistically-significant inferior outcomes compared to both EVLA and RFA regarding ulcer recurrence.

CONCLUSION

This is the first network meta-analysis examining the effect of various interventions on VLU disease. While we have demonstrated the efficacy of RFA and ELVA in ulcer recurrence prevention, our results regarding the impact of RFA and sclerotherapy on VLU healing and recurrence, respectively, should be interpreted with caution. In addition, this review raises questions concerning the value of surgery and perforator interventions in the treatment of VLU. Further research through randomized controlled trials is required.

CLINICAL IMPACT

Our review has revealed the significant efficacy of endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) in effectively reducing the incidence of ulcer recurrence when compared to compression monotherapy. These outcomes hold the potential to provide relevant insights to both medical practitioners and patients, thereby informing a more prudent and enlightened decision-making approach. Such informed decisions, aimed at mitigating the recurring occurrence of venous leg ulcers, carry profound significance given the considerable socioeconomic implications associated with this medical condition.

Comparable and Complimentary Modalities for Treatment of Small-Sized HCC: Surgical Resection, Radiofrequency Ablation, and Microwave Ablation

BACKGROUND

Over the past decade, there has been continual improvement in both ablative and surgical technologies for the treatment of hepatocellular carcinoma (HCC). The efficacy of ablative therapy compared to surgical resection for HCC has not been thoroughly evaluated using multiple large-scale randomized controlled trials. By international consensus, if a patient is eligible, surgery is the primary curative treatment option, as it is believed to confer superior oncologic control.

OBJECTIVE

to determine the efficacies of percutaneous ablative therapies and surgical resection (SR) in the treatment of HCC. Data sources, study appraisal, and synthesis methods: A meta-analysis using 5 online databases dating back to 1989 with more than 31,000 patients analyzing patient and tumor characteristics, median follow-up, overall survival, and complication rate was performed.

RESULTS

Ablative therapies are suitable alternatives to surgical resection in terms of survival and complication rates for comparable patient populations. For the entire length of the study from 1989-2019, radiofrequency ablation (RFA) produced the highest 5-year survival rates (59.6%), followed by microwave ablation (MWA) (50.7%) and surgical resection (SR) (49.9%). In the most recent era from 2006 to 2019, surgical resection has produced the highest 5-year survival rate of 72.8%, followed by RFA at 61.7% and MWA at 50.6%. Conclusions and key findings: Depending on the disease state and comorbidities of the patient, one modality may offer superior overall survival rates over the other available techniques. Interventional ablative methods and surgical resection should be used in conjunction for the successful treatment of small-sized HCC.

Systemic chemotherapy combined with radiofrequency ablation for colorectal cancer with liver metastasis: a retrospective cohort study

This study aims to evaluate the efficacy of systemic chemotherapy combined with radiofrequency ablation in the treatment of inoperable colorectal cancer with liver metastasis.

Materials and methods

The authors conducted a retrospective cohort analysis on 30 patients diagnosed as colorectal cancer with liver metastasis who underwent systemic chemotherapy combined with radiofrequency ablation of the liver lesions from January 2017 to August 2020 at our institution. Responses was evaluated by International Working Group on Image-guided Tumor Ablation criteria, along with progression-free survival.

Results

The response rate after 4 cycles and 8 cycles of chemotherapy were 73.3% and 85.2%, respectively. All patients achieved responses after of radiofrequency therapy, with the rates of complete response and partial response were 63.3% and 36.7%. The median progression-free survival was 16.7 months. After radiotherapy ablation, all patients had mild to moderate hepatic pain, 10% of patients had fever and increased liver enzymes occurred in 90% of patients.

Conclusions

Systemic chemotherapy combined with radiofrequency ablation was safe and effective in colorectal cancer with liver metastasis and warrants further large-scale studies.

A network meta-analysis on the efficacy and safety of thermal and nonthermal endovenous ablation treatments

OBJECTIVE

We assessed the mid-term efficacy and safety of thermal and nonthermal endovenous ablation for the treatment of lower limb superficial venous insufficiency.

METHODS

We performed a systematic review in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement and a Bayesian network meta-analysis. The primary end points were great saphenous vein (GSV) closure and venous clinical severity score (VCSS) improvement. A meta-regression using GSV diameter as a covariate was undertaken for the two primary end points.

RESULTS

We included 14 studies and 4177 patients, with a mean follow-up of 25.7 months. Radiofrequency ablation (RFA; odds ratio [OR], 3.99; 95% confidence interval [CI], 1.82-10.53), cyanoacrylate ablation (CAC; OR, 3.09; 95% CI, 1.35-8.37), and endovenous laser ablation (EVLA; OR, 2.72; 95% CI, 1.23-7.38) displayed increased odds for GSV closure compared with mechanochemical ablation (MOCA). MOCA inferiority compared with RFA (mean difference [MD], 0.96; 95% CI, 0.71-1.20), EVLA (MD, 0.94; 95% CI, 0.61-1.24), and CAC (MD, 0.89; 95% CI, 0.65-1.15) was also depicted regarding VCSS improvement. EVLA resulted in an increased risk of postoperative paresthesia compared with MOCA (risk ratio [RR], 9.61; 95% CI, 2.32-62.29), CAC (RR, 7.90; 95% CI, 2.44-38.16), and RFA (RR, 6.96; 95% CI, 2.31-28.04). Although the overall analysis identified nonstatistically significant differences for Aberdeen varicose vein questionnaire score improvement, thrombophlebitis, ecchymosis, and pain, further investigation revealed an increase pain profile for EVLA at 1470 nm compared with RFA (MD, 3.22; 95% CI, 0.93-5.47) and CAC (MD, 3.04; 95% CI, 1.05-4.97). A sensitivity analysis displayed a persistent underperformance of MOCA compared with RFA (OR, 4.33; 95% CI, 1.15-55.54) for GSV closure and both RFA (MD, 0.99; 95% CI, 0.22-1.77) and CAC (MD, 0.84; 95% CI, 0.08-1.65) regarding VCCS improvement. Although no regression model reached statistical significance, the GSV closure regression model revealed a trend for considerably decreased efficacy for both CAC and MOCA with larger GSV diameters compared with RFA and EVLA.

CONCLUSIONS

Although our analysis has produced skepticism regarding the efficacy of MOCA in the mid-term period for VCSS improvement and GSV closure rates, CAC showed equivalent results compared with both RFA and EVLA. Additionally, CAC displayed a decreased risk of postprocedural paresthesia and pigmentation and induration compared with EVLA. Also, both RFA and CAC had an improved pain profile compared with EVLA 1470 nm. The potential underperformance of nonthermal, nontumescent ablation modalities in ablating large GSVs necessitates further research.

Sequential therapy for pancreatic cancer patients with synchronous oligo-hepatic metastatic lesions

BACKGROUND

Treatments for patients suffering from pancreatic cancer with oligo-hepatic metastasis have always been a cause of certain controversy. Herein, we reported 15 pancreatic cancer patients with oligo-hepatic metastasis who accepted sequential therapy of chemotherapy, radiofrequency ablation (RFA), and radical resection of the primary tumor.

METHODS

A total of 87 pancreatic cancer patients with synchronous oligo-metastatic hepatic lesions who received treatments in the 2nd Affiliated Hospital of Zhejiang University between January 2017 and July 2020 were enrolled. The chemotherapy regimens included modified folfirinox (54/87) and gemcitabine plus nab-paclitaxel (33/87). Test of blood tumor markers and contrast-enhanced computed tomography (CT) or magnetic resonance (MR) scan was performed at diagnosis and after eight weeks of chemotherapy.

RESULTS

Thirty-five patients received just chemotherapy because of poor reaction to the first round of chemotherapy(Overall survival (OS), 6.47±1.80 months); 15 patients reassessed as stable disease (SD)/partial response (PR) continued chemotherapy (OS, 10.35±3.15); nine patients reassessed as progressive disease (PD) after RFA and continued chemotherapy (OS, 10.90±2.60). The primary tumors in 13 patients were unresectable after chemotherapy and RFA (OS, 12.92±2.47), while 15 patients completed the sequential therapy of chemotherapy, radio-frequency ablation, and radical resection (OS, 16.76±6.55).

CONCLUSIONS

Sequential chemotherapy and RFA is a good treatment strategy to select the best candidates for surgical treatment among patients with pancreatic cancer with oligo-hepatic metastasis.

Performance and Safety of EUS Ablation Techniques for Pancreatic Cystic Lesions: A Systematic Review and Meta-Analysis

BACKGROUND

Pancreatic cystic lesions (PCL) represent an increasingly diagnosed condition with significant burden to patients' lives and medical resources. Endoscopic ultrasound (EUS) ablation techniques have been utilized to treat focal pancreatic lesions. This systematic review with meta-analysis aims to assess the efficacy of EUS ablation on PCL in terms of complete or partial response and safety.

METHODS

A systematic search in Medline, Cochrane and Scopus databases was performed in April 2023 for studies assessing the performance of the various EUS ablation techniques. The primary outcome was complete cyst resolution, defined as cyst disappearance in follow-up imaging. Secondary outcomes included partial resolution (reduction in PCL size), and adverse events rate. A subgroup analysis was planned to evaluate the impact of the available ablation techniques (ethanol, ethanol/paclitaxel, radiofrequency ablation (RFA), and lauromacrogol) on the results. Meta-analyses using a random effects model were conducted and the results were reported as percentages with 95% confidence intervals (95%CI).

RESULTS

Fifteen studies (840 patients) were eligible for analysis. Complete cyst resolution after EUS ablation was achieved in 44% of cases (95%CI: 31-57; 352/767; I² = 93.7%), and the respective partial response rate was 30% (95%CI: 20-39; 206/767; I² = 86.1%). Adverse events were recorded in 14% (95%CI: 8-20; 164/840; I² = 87.2%) of cases, rated as mild in 10% (95%CI: 5-15; 128/840; I² = 86.7%), and severe in 4% (95%CI: 3-5; 36/840; I² = 0%). The subgroup analysis for the primary outcome revealed rates of 70% (95%CI: 64-76; I² = 42.3%) for ethanol/paclitaxel, 44% (95%CI: 33-54; I²= 0%) for lauromacrogol, 32% (95%CI: 27-36; I² = 88.4%) for ethanol, and 13% (95%CI: 4-22; I² = 95.8%) for RFA. Considering adverse events, the ethanol-based subgroup rated the highest percentage (16%; 95%CI: 13-20; I² = 91.0%).

CONCLUSION

EUS ablation of pancreatic cysts provides acceptable rates of complete resolution and a low incidence of severe adverse events, with chemoablative agents yielding higher performance rates.

Gastroesophageal Reflux Disease in 2023: When to Operate and Current Endoscopic Options for Antireflux Therapy

Gastroesophageal reflux disease (GERD) is among the most prevalent diseases in the United States. Mainstay therapy is lifestyle modification and medical therapy. If patients have GERD despite medical therapy, appropriate testing should be performed to determine if surgical or endoscopic therapy will provide improvement in their symptoms. Gold standard therapy is a minimally invasive fundoplication. Patients with body mass index <35, small or no hiatal hernia, normal motility, and pathologic GERD should consider magnetic sphincter augmentation. If a patient is not interested in either fundoplication or MSA, they should consider endoscopic treatment with either STRETTA or Transoral Incisionless fundoplication 2.0. A meta-analysis by Gong and colleagues showed that endoscopic treatments are better compared with medical therapy but are worse than surgical therapy.

Radiofrequency ablation for the treatment of a presumed enchondroma in the flat bones of the pelvis

Herein, a 30-year-old Caucasian female who presented with a persistent pain in the right pelvic region due to an enchondroma and treated with RF ablation is described. An initial MRI of the pelvis revealed a well-circumscribed lesion in the right inferior ischiopubic ramus with a maximum diameter of 9.5 mm. The final diagnosis was established by a percutaneous CT-guided bone biopsy, which excluded malignancy and revealed an enchondroma. About a month after the biopsy, a percutaneous radiofrequency ablation (RFA) of the lesion was performed. The symptoms resolved completely gradually 2 months after the treatment and a follow-up imaging with MRI showed complete resolution of the pathological enhancement indicating necrosis of the lesion. RFA has not been previously reported as a treatment option of enchondromas found in flat bones of the pelvis and could be a safe alternative minimally invasive treatment option in such cases, avoiding major operations.

Radiofrequency Ablation Provides Rapid and Durable Pain Relief for the Palliative Treatment of Lytic Bone Metastases Independent of Radiation Therapy: Final Results from the OsteoCool Tumor Ablation Post-Market Study

PURPOSE

The OsteoCool Tumor Ablation Post-Market Study (OPuS One) was a prospective, multi-national, single-arm study to investigate safety and effectiveness of radiofrequency ablation (RFA) for palliation of painful lytic bone metastases with 12 months of follow-up. RFA has demonstrated effective palliation of osseous metastases in small clinical studies with short-term follow-up; however, a long-term assessment with robust subject numbers is lacking.

MATERIALS AND METHODS

Prospective assessments were conducted at Baseline, 3 days, 1 week, and 1, 3, 6, and 12-months. Pain and quality of life were measured prior to RFA and postoperatively using the Brief Pain Inventory, European Quality of Life-5 Dimension, and European Organization for Research and Treatment of Cancer Care Quality of Life Questionnaire for palliative care. Radiation, chemotherapy and opioid usage, and related adverse events were collected.

RESULTS

206 subjects were treated with RFA at 15 institutions in OPuS One. Worst pain, average pain, pain interference and quality of life significantly improved at all visits starting 3 days post-RFA and sustained to 12 months (P < 0.0001). Post hoc analysis found neither systemic chemotherapy nor local radiation therapy at the index site of RFA influenced worst pain, average pain, or pain interference. Six subjects had device/procedure-related adverse events.

CONCLUSION

RFA for lytic metastases provides rapid (within 3 days) and statistically significant pain and quality of life improvements with sustained long-term relief through 12 months and a high degree of safety, independent of radiation.

LEVEL OF EVIDENCE

2B, PROSPECTIVE, NON-RANDOMIZED, POST-MARKET STUDY: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Sarcopenia as a Predictive Factor for Recurrence of Hepatocellular Carcinoma Following Radiofrequency Ablation

BACKGROUND

Sarcopenia is a skeletal muscle mass deficiency and a potential prognostic factor for the recurrence of hepatocellular carcinoma (HCC).

OBJECTIVE

To determine whether sarcopenia correlates with the recurrence rate of HCC after curative radiofrequency ablation (RFA) in early and very early HCC.

METHODS

We retrospectively reviewed 669 HCC patients who underwent their first curative RFA at Siriraj hospital from 2011 to 2020. Fifty-six patients who were diagnosed with HCC by triple-phase CT scan and had complete response on follow-up CT were included. All patients underwent skeletal muscle index (SMI) assessment at level L3 vertebra and sarcopenia was defined by the cut-off values of 52.4 cm2/m2 for men and 38.5 cm2/m2 for women. We compared patients with and without sarcopenia. Time to recurrence was evaluated by the Kaplan-Meier method. Univariate and multivariate Cox regression analysis was performed.

RESULTS

Sarcopenia was present in 37 of 56 patients (66.1%). There was no significant difference between groups except body mass index (BMI) (P<0.001) and serum alanine aminotransferase (ALT) (P=0.035). There was a promising result indicating the difference of time to recurrence between each group (P=0.046) and potential association of sarcopenia with HCC recurrence (HR=2.06; P=0.052). The Child-Pugh score and tumor number were independent risk factors for HCC recurrence (HR=2.04; P=0.005 and HR=2.68; P=0.017, respectively).

CONCLUSION

Sarcopenia is a potential prognostic factor for recurrence of HCC in Thai patients who underwent RFA. A larger study is required to properly confirm this association.

Efficacy and Safety of Endoscopic Ultrasound-Guided Radiofrequency Ablation for Pancreatic Neuroendocrine Tumors: A Systematic Review and Metanalysis

Introduction: The development of dedicated endoscopes and the technical evolution of endoscopic ultrasound (EUS) have allowed a direct approach to pancreatic neoplastic lesions both for diagnosis and treatment. Among the more promising targets are pancreatic neuroendocrine tumors (Pan-NETs). Aim: to describe the evolution of endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) with particular attention to the treatment of PanNETs, focusing on safety and clinical efficacy of the technique. Methods: MEDLINE, Scopus, and Cochrane Library databases were searched for studies reporting about EUS-RFA for the treatment of PanNETs. Studies with outcomes of interest were selected and results were reported to describe clinical success, complications, fol-low-ups, and electrodes used. Clinical success was defined as the disappearance of clinical symp-toms for functional (F-) PanNETs and as complete ablation per nonfunctional (NF)-PanNETs. The pooled data were analyzed by a random-effects model. Results: Nineteen studies were selected, including 183 patients (82 males, 44.8%) with 196 lesions (101 F-PanNETs and 95 NF-PanNETs). Pooled estimates for the overall AE rates for the clinical efficacy were 17.8% (95% CI 9.1-26.4%) and 95.1% (95% CI 91.2-98.9%) for F-PanNETs and 24.6% (95% CI 7.4-41.8%) and 93.4% (95% CI 88.4-98.4%) for NF-PanNETs. Conclusions: EUS-RFA appears to be a mini-invasive technique with a good safety and efficacy profile for the treatment of F- and NF-PanNETs. EUS-RFA could be of-fered as possible alternative to surgery for the treatment of low-grade NF- or F-PanNETs, especially for those patients that are not eligible or are at high-risk for surgery.

Radiofrequency Ablation of the Infrapatellar Branch of the Saphenous Nerve for the Treatment of Chronic Anterior Inferomedial Knee Pain

INTRO

Genicular nerve radiofrequency ablation (GNRFA) is an effective treatment for chronic knee pain related to osteoarthritis. It is often utilized when conservative management has failed and patients wish to avoid arthroplasty, are poor surgical candidates due to comorbid medical conditions, or in those suffering from persistent pain after arthroplasty. The classic targets for GNRFA include the superior lateral genicular nerve, superior medial genicular nerve, and inferior medial genicular nerve but multiple anatomic studies have demonstrated additional sensory innervation to the knee.

OBJECTIVE

In this research article, we propose an image-guided technique that can safely target the infrapatellar branch of the saphenous nerve which also provides sensory innervation to the anterior capsule.

PROPOSAL

The proposed technique includes variations for conventional bipolar radiofrequency ablation, cooled radiofrequency ablation, dual-tined bipolar radiofrequency ablation, and monopolar radiofrequency ablation using a long axis approach. The described technique is based on updated anatomic studies and takes into account safety concerns such as thermal risk to the skin and/or pes anserine tendons and breaching of the synovial cavity.

CONCLUSION

Future clinical research should be performed to confirm the safety and effectiveness of this specific approach.

Radiofrequency ablation is as safe and effective as surgical excision for spinal osteoid osteoma: a systematic review and meta-analysis

BACKGROUND

Osteoid osteoma (OO) is a primary benign tumor that affects mainly young patients. Ten percent of all OO are located in the vertebral column. Treatment of spinal OO is challenging and there is no consensus in the literature on the best operative approach.

PURPOSE

The aim of this systematic review and meta-analysis was to determine safety and efficacy of radiofrequency ablation (RFA) versus surgical excision for the treatment of spinal OO.

METHODS

A literature search was performed on PubMed, Web of Science, and Embase from inception up to 22 March 2022. Studies addressing surgical excision or RFA for the treatment of spinal OO were included. The main outcomes evaluated were pain before and after intervention, the treatments success rate, defined as complete pain relief with no recurrence until the last follow-up, and the number and type of complications.

RESULTS

Thirty-one studies (749 patients) were included. For patients who underwent surgical excision, 19 studies reported a mean treatment success rate of 85.6%, while in the RFA treatment group, 18 studies reported a mean success rate of 88.6%. At last follow-up, the pooled mean difference in pain scores from baseline on a 0-10 scale was 5.8 points in the surgical excision group and 6.7 points in the RFA group. Recurrences were observed in 5.6% of the patients who underwent surgical excision and in 6.7% of the patients treated with RFA. The complication rate was 7.8% in the surgical excision group and 4.4% in the RFA group.

CONCLUSIONS

This meta-analysis found high global success rates for both surgical and RFA treatments. Both treatments were efficient in pain relief and presented a low rate of recurrences. The complication rate was low for both treatments. Compared to surgical excision, RFA is a less invasive procedure which proved to be a safe and as effective option for the treatment of spinal OO.

The oligometastatic paradigm and the role of radiotherapy

Most cancer-related deaths are due to metastatic disease. There is now an emerging evidence base suggesting that a subgroup of metastatic patients benefit significantly from local resection (surgery) or ablation (stereotactic ablative body radiation, SABR) of their metastatic sites. These patients are in what has been termed the 'oligometastatic state', a transitional window between local and disseminated disease where locally ablative, metastasis-directed therapy prolongs progression-free survival, improves overall survival and sometimes achieves cure. Appropriately selecting those who fit this oligometastatic phenotype, while integrating advances in ablative technologies such as SABR with modern systemic treatments, is an evolving challenge for oncologists.

Radiofrequency Ablation of Indeterminate Thyroid Nodules: The First North American Comparative Analysis

Thyroid nodules can be classified as benign, malignant, or indeterminate, the latter of which make up 10-30% of nodules. Radiofrequency ablation (RFA) has become an attractive and promising therapy for the treatment of benign thyroid nodules. However, few studies have investigated the safety and efficacy of RFA for the management of indeterminate thyroid nodules. In this study, 178 patients with thyroid nodules diagnosed as benign (Bethesda II) or indeterminate (Bethesda III/IV) by preoperative cytopathological analysis were included. Patients in the benign and indeterminate cohorts had similar thyroid nodule volume reduction rates at 65.60% and 64.20%, respectively (p = 0.68). The two groups had similar nodular regrowth rates, at 11.2% for benign nodules and 9.40% for indeterminate nodules (p = 0.72). A total of three cases of transient dysphonia were reported. RFA of indeterminate thyroid nodules was comparable to that of benign thyroid nodules in all parameters of interest, including volume reduction rate. To our best knowledge, our work is the first North American analysis comparing benign and indeterminate thyroid nodules and suggests RFA to be a promising modality for the management of indeterminate thyroid nodules.

Evaluation of Correlation between Vitamin D Levels and Implant Stability in Indian Population: A Prospective Study in Bangalore

Purpose

Dental implants have become a definitive method for the esthetic and functional rehabilitation of both partially and completely edentulous arch. There is a significant role of vitamin D in bone metabolism and there are only few human studies that evaluate the effect of vitamin D deficiency on stability of dental implants. The study thus aims to evaluate the correlation of vitamin D deficiency and implant stability in delayed endosseous implant.

Methods

The study included 20 subjects of either gender in the age group of 20-50 years, who required implant placement for rehabilitation of partially edentulous condition. Vitamin D status was evaluated for all subjects preoperatively. Implant stability was checked postoperatively at three months and six months using Electronic Technology Resonance Frequency Analysis.

Results

The study found that for every 1 ng/ml increase in Vitamin D levels, the implant stability Quotient value (ISQ) significantly increased by 0.48 at 3 months and 0.62 units at 6 months, which was statistically significant at P = 0.01 and P = 0.002, respectively. Statistical analysis was done using Student Paired t test, Pearson Correlation test and Simple Linear regression analysis.

Conclusion

Albeit the smaller sample size, the results of the study showed the positive influence of vitamin D on stability of implant. The study thus emphasizes on the significance of screening the vitamin D status of subjects prior to implant placement.

Dropped head syndrome: report of a rare complication after multilevel bilateral cervical radiofrequency neurotomy

Dropped head syndrome is a rarely discussed complication of cervical radiofrequency neurotomy. Here, we review presentation, management, and possible mitigating factors of this complication.

Introduction:

Cervical radiofrequency neurotomy is a safe and relatively low-risk procedure commonly used to treat facet joint–mediated axial neck pain. Severe complications are extremely rare and can be avoided with proper technique and appropriate imaging guidance. This article describes the development and subsequent management of a case of dropped head syndrome after cervical radiofrequency neurotomy.

Methods:

A 77-year-old man with cervicalgia, multilevel facet arthropathy, and a known kyphosis in the setting of cervical degenerative disk disease underwent successful conventional radiofrequency neurotomy to the bilateral C3, C4, and C5 medial branches. No immediate complications were noted.

Results:

Six weeks subsequent to the procedure, the patient reported difficulty keeping his head erect, and physical examination revealed weakness of the cervical paraspinal musculature, with restriction of active extension to about neutral. A diagnosis of dropped head syndrome was made. The patient was successfully managed with temporary use of soft cervical collar and physical therapy for progressive range of motion and strengthening.

Discussion:

Dropped head syndrome is a known, but likely underappreciated, complication of cervical radiofrequency neurotomy, with only 2 other cases reported and published in the literature to our knowledge. Mild cases may resolve with conservative management, but this is a potentially debilitating condition that we recommend should be routinely discussed during procedural consent for cervical radiofrequency neurotomy. Future studies should explore specific mitigating factors to reduce the risk of development of this possible complication.

Outcomes of Radiofrequency Ablation Compared to Liquid Nitrogen Spray Cryotherapy for the Eradication of Dysplasia in Barrett's Esophagus

INTRODUCTION

Current guidelines recommend endoscopic eradication therapy (EET) for Barrett's esophagus (BE) with dysplasia and intramucosal adenocarcinoma using either radiofrequency ablation (RFA) or liquid nitrogen spray cryotherapy (LNSC). The aims of this multicenter study are to compare the rate and number of treatment sessions of RFA vs. LNSC to achieve CE-D and CE-IM and assess outcomes for those who switched therapy.

METHODS

This is a retrospective cohort study of patients with BE undergoing EET. Demographics, baseline variables, endoscopy details, and histology information were abstracted.

RESULTS

One hundred and sixty-two patients were included in this study with 100 patients in the RFA group and 62 patients in the LNSC group. The rate of CE-D and CE-IM did not differ between the RFA group and LNSC group (81% vs. 71.0%, p = 0.14) and (64% vs. 66%, p = 0.78), respectively. The number of sessions to achieve CE-D and CE-IM was higher with LNSC compared to RFA (4.2 vs. 3.2, p = 0.05) and (4.8 vs. 3.5, p = 0.04), respectively. The likelihood of developing recurrent dysplasia was higher among patients who did not achieve CE-IM (12%) compared to those who did achieve CE-IM (4%), p = 0.04. Similar findings were found in those who switched treatment modalities.

DISCUSSION

EET is highly effective in eradication of Barrett's associated dysplasia and neoplasia. Both RFA and LNSC achieved similar rates of CE-D and CE-IM although LNSC required more sessions. Also, achievement of CE-IM was associated with less recurrence rates of dysplasia.

Management of uncomplicated total knee arthroplasty chronic pain and stiffness utilizing cooled radiofrequency ablation: a single institution pilot study

OBJECTIVE

The objective of this study is to introduce cooled radiofrequency ablation technical feasibility as an alternative percutaneous image-guided treatment of chronic pain and stiffness in the setting of uncomplicated total knee arthroplasty.

MATERIAL AND METHOD

This retrospective pilot study includes a total of 19 consecutive patients experiencing persistent chronic pain after total knee arthroplasty, without underlying hardware complications who had failed conservative care. Patients initially underwent anesthetic blocks of the genicular nerve branches to determine C-RFA candidacy. After adequate response to the anesthetic blocks (> 50% immediate pain relief), patients were subjected to cooled radiofrequency ablations 2-3 weeks later. Treatment response was evaluated utilizing clinically validated questionnaires (KOOS, the Knee Injury and Osteoarthritis Outcome Score) and visual analog scale (VAS) to assess pain severity, stiffness, functional activities of daily living, and use of pain medication. Follow-up outcome scores were collected up to 1 year after C-RFA procedure.

RESULT

A total of 21 knees were treated consecutively between 4/2019 and 1/2020 (mean age 70.5 years; 5 M:14F). The mean total KOOS score improved significantly from baseline at 35.0 ± 14.0 to 64.2 ± 14.7 at a mean of 10.2 months after treatment (p < 0.0001), with significant improvement in mean stiffness score from 44.8 ± 16.7 to 68.8 ± 20 (p < 0.0001). The mean VAS score improved significantly from baseline at 8.30 ± 1.1 to 2.45 ± 1.8 (p < 0.0001). No major complications were encountered. No patients went on to receive re-treatment, surgical revision, or other intervention.

CONCLUSION

Image-guided genicular nerve cooled radiofrequency ablation offers a promising alternative in treating chronic pain/stiffness in the setting of uncomplicated TKA.

Complications after Thermal Ablation of Hepatocellular Carcinoma and Liver Metastases: Imaging Findings

Tumour ablation is a strategy of treatment of hepatic tumours in patients with small hepatocellular carcinoma (HCC) (<3 cm) or in patients unfit for surgical resection. Moreover, tumor ablation can be used as an adjuvant therapy or may be used in association with resection in case of patients with poor functional liver disease. These types of treatment usually could be performed percutaneously under image guidance. The most clinically verified and used ablation modalities are Radiofrequency Ablation (RFA) and microwave ablation (MWA). However, despite both of them are considered minimally invasive techniques, they could be related to post-procedural complications. The International Working Group on Image-Guided Tumor and the Society of Interventional Radiology (SIR) identified major and minor post-ablative complications. Major complications, as vascular complications, occur in 2.2% to 3.1% of cases and include all the high risk pathological conditions which could increase the level of care or result in hospital admission or substantially prolonged hospital stay (SIR classifications C−E). Minor complications, as biliary complications, occur in 5% to 8.9% and include self-limiting conditions that are considered to be of low risk for the patient’s outcome. The purpose of this review is to summarise the main pathological ultrasound (US) and Computed Tomography (CT) findings, that may arise after ablative treatment. To simplify the analysis, the pathological pictures are divided according to the site of damage into vascular, biliary and extrahepatic complications.

Primary Implant Stability Analysis of Different Dental Implant Connections and Designs-An In Vitro Comparative Study

Primary implant stability can be evaluated at the time of placement by measuring the insertion torque (IT). However, another method to monitor implant stability over time is resonance frequency analysis (RFA). Our aim was to examine the effect of bone type, implant design, and implant length on implant primary stability as measured by IT and two RFA devices (Osstell and Penguin) in an in vitro model. Ninety-six implants were inserted by a surgical motor in an artificial bone material, resembling soft and dense bone. Two different implant designs-conical connection (CC) and internal hex (IH), with lengths of 13 and 8 mm, were compared. The results indicate that the primary stability as measured by RFA and IT is significantly increased by the quality of bone (dense bone), and implant length and design, where the influence of dense bone is similar to that of CC design. Both the Osstell and Penguin devices recorded higher primary implant stability for long implants in dense bone, favoring the CC over the IH implant design. The CC implant design may compensate for the low stability expected in soft bone, and dense bone may compensate for short implant length if required by the anatomical bone conditions.

Anterior accessory great saphenous vein as a cause of postoperative recurrence of veins after radiofrequency ablation

There are problems of postoperative relapse of veins after radiofrequency ablation (RFA). The study aims to analyze the causes of postoperative recurrence of veins after RFA. 928 patients with varicose veins of the lower extremities, clinical classes C₂-C₄ according to the CEAP classification, were treated in the ambulatory surgery centers using RFA. The causes of varicose recurrence showed that it was caused by: a) high fusion of the anterior accessory great saphenous vein (AAGSV) with great saphenous vein (GSV) directly in the saphenofemoral junction (SFJ), which was not revealed by preoperative ultrasound (1.7%); a long stump of the GSV after the RFA (7.8%); progression of varicose disease with the small saphenous vein (SSV) and formation of new reflux associated with insufficiency of the saphenopopliteal junction (SPJ) (4.7%); d) insufficiency of perforating veins of the tibioperoneal group (Sherman, Boyd), as well as Gunter (3.8%); e) neovascularization with dilation of small vessels in the area of the saphenofemoral junction (0.97%). A comparative assessment of the quality of life (QL) after different surgery methods 3 years after implementation was carried out. Thus, QL in all patients who underwent surgery significantly improved than before surgery. However, after the RFA GSV+AAGSV, the patients had better QL by all scales than those who underwent only RFA GSV. Operations performed simultaneously on GSV and AAGSV have better functionality than GSV-only RFA.

Early and midterm results of radiofrequency ablation (Rafaelo® procedure) for third-degree haemorrhoids: a prospective, two-centre study

Background

The aim of this study was to evaluate the safety and efficacy of radiofrequency ablation (RFA) for treating third degree haemorrhoids, with a follow-up over 2 years.

Methods

We conducted a prospective, two-centre study to assess RFA of third-degree haemorrhoids in an outpatient setting. Treatment was performed under local anaesthesia, optionally in combination with sedation. The primary endpoint was analysis of a proctological symptom score ([PSS] bleeding, itching, pain, soiling) and proctological examination to detect recurrence at 1, 6, 12 and 24 months after surgery. The secondary endpoints were postoperative complications, incidence of postoperative pain, including administration of analgesics and time to return to daily routine.

Results

Ninety-eight patients were included in the study. The mean age of the patients was 49.1 ± 10.9 (mean ± SD). 83 patients (84.7%) were male and 15 patients (15.3%) were female. The follow-up involved 100% (1 month), 95% (6 months), 86% (12 months) and 74% after 24 months. The individual symptom scores and overall PSS score decreased significantly in comparison to the initial score at each time point assessed. Prolapsed haemorrhoids decreased in comparison to the initial situation (100%) to 7.2% (1 month), 3.5% (6 months), 13.1% (12 months) and 13.7% (after 24 months). Thirteen patients (12.7%) required repeat haemorrhoid therapy during the 2-year follow-up period. The mean maximum pain score after the procedure was 2.5 ± 2.7 (determined with the visual analogue scale), while 33 (33.7%) patients reported having no pain. 59 (60.2%) patients did not take analgesics after the procedure. Eleven patients (11.2%) experienced minor complications (bleeding, fever, cramps, diarrhoea, anal venous thrombosis) but did not require additional treatment. Eight cases (8.2%) of major complications (infection, bleeding, severe pain) required treatment with antibiotics, a second intervention, analgesics or hospitalization.

Conclusions

RFA is safe and effective for treatment of third-degree haemorrhoids. The main advantages of this new method are its use on an outpatient basis under local anaesthesia, a very low level of postoperative pain and significant control of haemorrhoid symptoms over 2 years.

Physical radiofrequency adjuvant enhances immune responses to influenza H5N1 vaccination

Pre-pandemic influenza H5N1 vaccine has relatively low immunogenicity and often requires high antigen amounts and two immunizations to induce protective immunity. Incorporation of vaccine adjuvants is promising to stretch vaccine doses during pandemic outbreaks. This study presents a physical radiofrequency (RF) adjuvant (RFA) to conveniently and effectively increase the immunogenicity and efficacy of H5N1 vaccine without modification of vaccine preparation. Physical RFA is based on a brief RF treatment of the skin to induce thermal stress to enhance intradermal vaccine-induced immune responses with minimal local or systemic adverse reactions. We found that physical RFA could significantly increase H5N1 vaccine-induced hemagglutination inhibition antibody titers in murine models. Intradermal H5N1 vaccine in the presence of RFA but not vaccine alone significantly lowered lung viral titers, reduced body weight loss, and improved survival rates after lethal viral challenges. The improved protection in the presence of RFA was correlated with enhanced humoral and cellular immune responses to H5N1 vaccination in both male and female mice, indicating no gender difference of RFA effects in murine models. Our data support further development of the physical RFA to conveniently enhance the efficacy of H5N1 vaccine.

Comparison of combined transarterial chemoembolization and ablations in patients with hepatocellular carcinoma: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis compares the efficacy of three combination therapies, including transarterial chemoembolization (TACE) with radiofrequency ablation (RFA), microwave ablation (MWA), and cryoablation (CRA) for the treatment of patients with hepatocellular carcinoma (HCC).

METHODS

Online databases, including Scopus, Web of Science, PubMed, Embase, CNKI, Google Scholar, and Cochrane Library were searched.

RESULTS

Forty-two studies with 5468 pooled patients (TACE + RFA: 21 studies with 3398 patients, TACE + MWA:14 studies with 1477 patients, and TACE + CRA: 7 studies with 593 patients) reported combination therapy versus TACE alone. The TACE + MWA subcohort had the best odds of long-term overall survival (OR 4.81, 95% CI 1.44, 16.08, P = 0.011) and objective response rate (OR 3.93, 95% CI 2.34, 6.61, P < 0.001) compared with the other two combination subcohorts. The TACE + RFA and TACE + MWA subcohorts had approximately similar odds of 1-year recurrence-free survival (OR 5.21, 95% CI 2.13, 12.75, P < 0.001 and OR 4.61, 95% CI 1.70, 12.51, P = 0.003, respectively). The disease control rate was similar between the TACE + MWA and TACE + CRA subcohorts (OR 4.01, 95% CI 2.66, 6.04, P < 0.001 and OR 4.05, 95% CI 1.68, 9.74, P = 0.002) but greater than the TACE + RFA subcohort (OR 3.23, 95% CI 2.14, 4.86, P < 0.001).

CONCLUSION

Overall, the TACE + MWA subcohort had the best efficacy and outcomes, especially for younger patients (less than 60-year-old) with tumor size of ≤ 3 cm, compared with the TACE + RFA or TACE + CRA subcohorts.

Balloon-Occluded Radiofrequency Ablation as Bridge to TACE in the Treatment of Advanced HCC with Arterioportal Shunt

BACKGROUND

Transarterial chemoembolization is the most widely used palliative treatment for unresectable hepatocellular carcinoma; however, arterioportal shunt represents a contraindication to this treatment.

OBJECTIVE

To assess the feasibility of balloon-occluded radiofrequency ablation in the transitory resolution of extensive arterioportal shunt in patients with advanced hepatocellular carcinoma as a bridge to safe and effective transarterial chemoembolization.

METHODS

12 consecutive patients with advanced multinodular unilobar unresectable hepatocellular carcinoma with a target lesion larger than 5 cm (mean diameter 7.7 ± 1.4 cm), not suitable to transarterial chemoembolization due to extensive arterioportal shunt were recruited. Balloon-occluded radiofrequency ablation of the hepatic area surrounding the shunt during occlusion of the artery supplying the shunt was performed, followed by lobar conventional chemoembolization. Intra/periprocedural complications were evaluated. Technical success was defined by the result of radiofrequency ablation in terms of immediate disappearance, reduction or persistence of the shunt. Local efficacy of chemoembolization was evaluated at 1-month computed tomography according to m-RECIST criteria.

RESULTS

Technical success was achieved in all patients. No major complications were observed. 1-month follow-up showed a mean necrotic diameter of 6.3 cm (range: 3.8-8.7 cm), with an acceptable procedural result and persistence of the shunt. An overall response rate was obtained in all patients, with 25% complete response and 75% partial response.

CONCLUSION

Balloon-occluded radiofrequency ablation of arterioportal shunt in patients with advanced hepatocellular carcinoma can temporarily reduce shunting, allowing to perform a safe and therapeutically useful chemoembolization, with a satisfactory control of tumor growth.