Endotracheal enucleation and para-toluenesulfonamide injection for adenoid cystic carcinoma in the upper trachea: A novel therapeutic approach

We present a case of an adenoid cystic carcinoma (ACC) located in the upper trachea, which resulted in significant airway blockage, that was unsuitable for surgical removal due to concerns about functional impairment. Instead, endotracheal enucleation via rigid bronchoscopy was performed initially, followed by the injection of a novel tumor ablation agent known as para-toluenesulfonamide (PTS). We detail the dosing regimen, effectiveness evaluation, and post-treatment follow-up. The study highlights the potential of PTS injection as a viable alternative treatment option for patients with ACC who cannot undergo surgical resection and feasibility of lipiodol to monitor treatment effect. This research adds to the existing knowledge on ACC treatment and provides new therapeutic possibilities for patients with tracheal ACC.

Transbronchial Microwave Ablation of Peripheral Lung Tumors: The NAVABLATE Study

BACKGROUND

Image-guided thermal ablation is a minimally invasive local therapy for lung malignancies. NAVABLATE characterized the safety and performance of transbronchial microwave ablation (MWA) in the lung.

METHODS

The prospective, single-arm, 2-center NAVABLATE study (NCT03569111) evaluated transbronchial MWA in patients with histologically confirmed lung malignancies ≤30 mm in maximum diameter who were not candidates for, or who declined, both surgery and stereotactic body radiation therapy. Ablation of 1 nodule was allowed per subject. The nodule was reached with electromagnetic navigation bronchoscopy. Cone-beam computed tomography was used to verify the ablation catheter position and to evaluate the ablation zone postprocedure. The primary end point was composite adverse events related to the transbronchial MWA device through 1-month follow-up. Secondary end points included technical success (nodule reached and ablated according to the study protocol) and technique efficacy (satisfactory ablation based on 1-month follow-up imaging).

RESULTS

Thirty subjects (30 nodules; 66.7% primary lung, 33.3% oligometastatic) were enrolled from February 2019 to September 2020. The pre-procedure median nodule size was 12.5 mm (range 5 to 27 mm). Procedure-day technical success was 100% (30/30), with a mean ablative margin of 9.9±2.7 mm. One-month imaging showed 100% (30/30) technique efficacy. The composite adverse event rate related to the transbronchial MWA device through 1-month follow-up was 3.3% (1 subject, mild hemoptysis). No deaths or pneumothoraces occurred. Four subjects (13.3%) experienced grade 3 complications; none had grade 4 or 5.

CONCLUSION

Transbronchial microwave ablation is an alternative treatment modality for malignant lung nodules ≤30 mm. There were no deaths or pneumothorax. In all, 13.3% of patients developed grade 3 or above complications.

Additional local therapy before disease progression for EGFR-mutated advanced lung cancer: a systematic review and meta-analysis

Background

International guidelines recommend the use of local therapy (LT) to limited progression in patients with epidermal growth factor receptor (EGFR)-mutated advanced non-small cell lung cancer (NSCLC). However, the use of LT before disease progression has not been extensively analyzed. This meta-analysis evaluates the efficacy and safety of administering additional LT in conjunction with first-line EGFR-tyrosine kinase inhibitors (TKIs) before disease progression in patients with EGFR-mutated advanced NSCLC.

Methods

We systematically searched PubMed, Embase, and the Cochrane Library for studies published up until May 31, 2023. The LT group consisted of patients who received first-line EGFR-TKIs in conjunction with additional LT, while the TKI group comprised participants treated with first-line EGFR-TKIs alone. Studies comparing the survival outcomes of the LT and TKI groups were included in this analysis. The primary outcomes were progression-free survival (PFS) and overall survival (OS). This review was registered on PROSPERO (registration number CRD42023439913).

Results

Among the 11 investigated studies covering 1,313 patients, the LT modalities included radiotherapy, surgery, and ablation therapy, which accounted for 91%, 27%, and 27% of the studies, respectively. The pooled hazard ratios of median PFS and OS were 0.34 [95% confidence interval (CI): 0.22-0.53; P<0.001] and 0.42 (95% CI: 0.36-0.48; P<0.001), respectively, which indicated significant benefits for the LT group compared to the TKI group. There was no significant difference between the LT and TKI groups (P=0.473) regarding the incidence of grade 3 or higher adverse events.

Conclusions

This study suggests that the strategic use of additional LT before disease progression is a promising approach for the treatment of EGFR-mutated advanced NSCLC.

Three-dimensional ultrasound fusion imaging in precise needle placement for thermal ablation of hepatocellular carcinoma

PURPOSE

To investigate the value of three-dimensional ultrasound fusion imaging (3DUS FI) technique for guiding needle placement in hepatocellular carcinoma (HCC) thermal ablation.

METHODS

A total of 57 patients with 60 HCCs with 3DUS FI-guided thermal ablation were retrospectively included in the study. 3DUS volume data of liver were acquired preoperatively by freehand scanning with the tumor and predetermined 5 mm ablative margin automatically segmented. Plan of needle placement was made through a predetermined simulated ablation zone to ensure a 5 mm ablative margin with the coverage rate toward tumor and ablative margin. With real-time ultrasound and 3DUS fusion imaging, ablation needles were placed according to the plan. After ablation, the ablative margin was immediately evaluated by contrast-enhanced ultrasound and 3DUS fusion imaging. The rate of adequate ablative margin, complete response (CR), local tumor progression (LTP), disease-free survival (DFS), and overall survival (OS) was evaluated.

RESULTS

According to postoperative contrast-enhanced CT or MR imaging, the complete response rate was 100% (60/60), and 83% of tumors (30/36) achieved adequate ablative margin (>5 mm) three-dimensionally. During the follow-up period of 6.0-42.6 months, LTP occurred in 5 lesions, with 1- and 2-year LTP rates being 7.0% and 9.4%. The 1- and 2-year DFS rates were 76.1% and 65.6%, and 1- and 2-year OS rates were 98.1% and 94.0%. No major complications or ablation-related deaths were observed in any patients.

CONCLUSIONS

Three-dimensional ultrasound fusion imaging technique may improve the needle placement of thermal ablation for HCC and reduce the rate of LTP.

Focal Minimally Invasive Treatment in Localized Prostate Cancer: Comprehensive Review of Different Possible Strategies

BACKGROUND

Focal therapy is a promising, minimally invasive method for the treatment of patients with localized prostate cancer. According to the existing literature, there is growing evidence for positive functional outcomes and oncological effectiveness. The aim of this review is to evaluate the technical efficacy of three minimally invasive techniques (cryoablation, electroporation, and microwave ablation) and their impact on quality of life in patients with prostate cancer.

METHODS

Studies between January 2020 and July 2023 were selected using PubMed, Embase, and The Cochrane Library and analyzed following PRISMA guidelines; they have not been registered.

RESULTS

Twenty-three studies investigating three different sources of energy to deliver focal therapy were found. Thirteen studies evaluated the performance of the cryoablation therapy, seven studies of the irreversible electroporation, and three studies of microwave ablation option. The majority of studies were retrospective cohort studies. Cryoablation showed excellent oncological outcomes for low-grade prostate cancer, whether performed on the lesion, on the hemigland, or on the entire gland, with the best results obtained for patients with intermediate risk. Irreversible electroporation showed promising oncological outcomes with no significant changes in functional outcomes. Microwave ablation showed great early functional outcomes.

CONCLUSIONS

The oncological effectiveness of minimally invasive treatment in comparison to standard of care is still under investigation, despite encouraging results in terms of functional outcomes improvement and adverse events reduction. More comprehensive research is needed to fully understand the function of minimally invasive treatment in patients with localized PCa.

Percutaneous microwave ablation versus sclerotherapy for large hepatic hemangioma: a multi-center cohort study

OBJECTIVE

The study aimed to compare the effectiveness and safety of ultrasound-guided microwave ablation (MWA) and percutaneous sclerotherapy (PS) for the treatment of large hepatic hemangioma (LHH).

METHODS

This retrospective study included 96 patients who underwent MWA (n = 54) and PS (n = 42) as first-line treatment for LHH in three tertiary hospitals from January 2016 to December 2021. Primary outcomes were technique efficacy rate (volume reduction rate [VRR] > 50% at 12 months), symptom relief rate at 12 months and local tumor progression (LTP). Secondary outcomes included procedure time, major complications, treatment sessions, cost and one-, two-, three-year VRR.

RESULTS

During a median follow-up of 36 months, the MWA group showed a higher technique efficacy rate (100% vs. 90.4%, p = .018) and symptom relief rate (100% vs. 80%, p = .123) than the PS group. The MWA group had fewer treatment sessions, higher one-, two- and three-year VRR, lower LTP rate (all p < .05), longer procedure time and higher treatment costs than the PS group (both p < .001). MWA shared a comparable major complications rate (1.8% vs. 2.4%, p = .432) with PS. After multivariate analysis, the lesion's heterogeneity and maximum diameter >8.1 cm were independent risk factors for LTP (all p < .05). In the PS group, lesions with a cumulative dose of bleomycin > 0.115 mg/cm3 had a lower risk of LTP (p = .006).

CONCLUSIONS

Both MWA and PS treatments for large hepatic hemangioma are safe and effective, with MWA being superior in terms of efficacy.

Economic evaluation of first-line cryoballoon ablation versus antiarrhythmic drug therapy for the treatment of paroxysmal atrial fibrillation from an English National Health Service perspective

INTRODUCTION

Three recent randomised controlled trials have demonstrated that pulmonary vein isolation as an initial rhythm control strategy with cryoablation reduces atrial arrhythmia recurrence in patients with symptomatic paroxysmal atrial fibrillation (PAF) compared with antiarrhythmic drug (AAD) therapy. The aim of this study was to evaluate the cost-effectiveness of first-line cryoablation compared with first-line AADs for treating symptomatic PAF in an English National Health Service (NHS) setting.

METHODS

Individual patient-level data from 703 participants with PAF enrolled into Cryo-FIRST (Catheter Cryoablation Versus Antiarrhythmic Drug as First-Line Therapy of Paroxysmal Atrial Fibrillation), STOP AF First (Cryoballoon Catheter Ablation in an Antiarrhythmic Drug Naive Paroxysmal Atrial Fibrillation) and EARLY-AF (Early Aggressive Invasive Intervention for Atrial Fibrillation) were used to derive the parameters applied in the cost-effectiveness model (CEM). The CEM comprised a hybrid decision tree and Markov structure. The decision tree had a 1-year time horizon and was used to inform the initial health state allocation in the first cycle of the Markov model (40-year time horizon; 3-month cycle length). Health benefits were expressed in quality-adjusted life years (QALYs). Costs and benefits were discounted at 3.5% per year. Model outcomes were generated using probabilistic sensitivity analysis.

RESULTS

The results estimated that cryoablation would yield more QALYs (+0.17) and higher costs (+£641) per patient over a lifetime than AADs. This produced an incremental cost-effectiveness ratio of £3783 per QALY gained. Independent of initial treatment, individuals were expected to receive ~1.2 ablations over a lifetime. There was a 45% relative reduction in time spent in AF health states for those initially treated with cryoablation.

DISCUSSION

AF rhythm control with first-line cryoablation is cost effective compared with first-line AADs in an English NHS setting.

Ultrasound-guided percutaneous thermal ablation of parotid tumors: experience from two-centers

Objective: To evaluate the efficacy and feasibility of ultrasound-guided percutaneous thermal ablation (TA) for treating benign parotid tumors.Methods: Patients with benign parotid tumors who underwent ultrasound-guided microwave ablation (MWA) or radiofrequency ablation (RFA) between January 2020 and March 2023 were included in this retrospective study. Change in tumor size (maximum diameter, tumor volume(V), volume reduction rate (VRR)) and cosmetic score (CS) were evaluated during a one-year follow-up period. We also recorded the incidence of any complications associated with TA.Results: A total of 23 patients (13 males and 10 females; median age 65 years, range 5-91 years) were included. The mean VRR at 1, 3, 6, and 12 months after TA was 37.03%±10.23%, 56.52%±8.76%, 82.28%±7.89%, and 89.39%±6.45%, respectively. Mean CS also changed from 3.39 ± 0.66 to 1.75 ± 0.93 (p < 0.001) by the end of follow-up time. Subgroup analysis showed that tumors with smaller initial maximum diameter had a faster CS reduction rate than those with larger initial diameter. The incidence of facial nerve dysfunction was 8.70%.Conclusion: Ultrasound-guided percutaneous TA is an effective and safe treatment option for patients with benign parotid tumors.

50-W vs 40-W During High-Power Short-Duration Ablation for Paroxysmal Atrial Fibrillation: A Multicenter Prospective Study

BACKGROUND

High-power short-duration (HPSD) radiofrequency ablation of atrial fibrillation (AF) increases first-pass pulmonary vein isolation (PVI) and freedom from atrial arrhythmias while decreasing procedural time. However, the optimal power setting in terms of safety and efficacy has not been determined.

OBJECTIVES

This study compared the procedural characteristics and clinical outcomes of 50-W vs 40-W during HPSD ablation of paroxysmal AF.

METHODS

Patients from the REAL-AF prospective multicenter registry (Real-World Experience of Catheter Ablation for Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation) undergoing HPSD ablation of paroxysmal AF, either using 50-W or 40-W, were included. The primary efficacy outcome was freedom from all-atrial arrhythmias. The primary safety outcome was the occurrence of any procedural complication at 12 months. Secondary outcomes included procedural characteristics, AF-related symptoms, and the occurrence of transient ischemic attack or stroke at 12 months.

RESULTS

A total of 383 patients were included. Freedom from all-atrial arrhythmias at 12 months was 80.7% in the 50-W group and 77.3% in the 40-W group (Log-rank P = 0.387). The primary safety outcome occurred in 3.7% of patients in the 50-W group vs 2.8% in the 40-W group (P = 0.646). The 50-W group had a higher rate of first-pass PVI (82.3% vs 76.2%; P = 0.040) as well as shorter procedural (67 minutes [IQR: 54-87.5 minutes] vs 93 minutes [IQR: 80.5-111 minutes]; P < 0.001) and radiofrequency ablation times (15 minutes [IQR: 11.4-20 minutes] vs 27 minutes [IQR: 21.5-34.6 minutes]; P < 0.001) than the 40-W group.

CONCLUSIONS

There was no significant difference in freedom from all-atrial arrhythmias or procedural safety outcomes between 50-W and 40-W during HPSD ablation of paroxysmal AF. The use of 50-W was associated with a higher rate of first-pass PVI as well as shorter procedural times.

Five-year Outcome Between Radiofrequency Ablation vs Surgery for Unilateral Multifocal Papillary Thyroid Microcarcinoma

CONTEXT

Ultrasound (US)-guided radiofrequency ablation (RFA) has been considered as an alternative to surgery or active surveillance for papillary thyroid microcarcinoma (PTMC). However, little is known about the long-term outcomes of RFA in comparison with surgery for unilateral multifocal PTMC.

OBJECTIVE

This work aims to report the comparison between RFA vs surgery for unilateral multifocal PTMC over a more than 5-year follow-up period.

METHODS

This was a retrospective study at a primary care center with a median follow-up period of 72.9 months. A total of 97 patients with unilateral multifocal PTMC were treated with RFA (RFA group, n = 44) or surgery (surgery group, n = 53). In the RFA group, patients were treated by a bipolar RFA generator and an 18-gauge bipolar RF electrode with a 0.9-cm active tip. In the surgery group, patients underwent thyroid lobectomy with prophylactic central neck dissection.

RESULTS

During the follow-up, no statistically significant differences were found in disease progression (4.5% vs 3.8%; P = ≥.999), lymph node metastasis (2.3% vs 3.8%; P = ≥.999), persistent lesion (2.3% vs 0%; P = .272), and RFS rates (97.7% vs 96.2%; P = .673) in the RFA and surgery groups. Patients undergoing RFA had a shorter hospitalization (0 vs 8.0 [3.0] d; P < .001), shorter procedure time (3.5 [2.4] vs 80.0 [35.0] min; P < .001), lower estimated blood loss (0 vs 20.0 [15.0] mL; P < .001), and lower costs ($1768.3 [0.1] vs $2084.4 [1173.8]; P = .001) than those in the surgery group. The complication rate in the surgery group was 7.5%, whereas none of the RFA-treated patients experienced any complications (P = .111).

CONCLUSION

This study revealed 6-year comparable outcomes between RFA and surgery for unilateral multifocal PTMC. RFA may be a safe and effective alternative to surgery in selected patients with unilateral multifocal PTMC.

Optimal endoscopic treatment and partial cystectomy with or without bladder augmentation for Hunner-type interstitial cystitis

Interstitial cystitis/bladder pain syndrome (IC/BPS) presents a significant challenge for urologists in terms of management, owing to its chronic nature and adverse impact on patient quality of life. Given the potential distinction between two disease entities within IC/BPS, namely Hunner-type IC and BPS without Hunner lesion, there is a need for an optimal therapeutic approach that focuses on the bladder lesions in Hunner-type IC. In cases where Hunner lesions are observed, complete transurethral ablation of these lesions should be prioritized as the initial intervention, as it has demonstrated effectiveness in symptom control. However, recurrence remains a limitation of this intervention. The techniques of resection and coagulation are equally effective in terms of symptom relief and recurrence prevention. Reconstructive surgery becomes necessary in cases of end-stage IC/BPS where various therapeutic approaches have failed. Patient selection is crucial in reconstructive surgery, particularly for patients with clear Hunner lesions and small bladder capacity who have not responded to previous treatments. Furthermore, it is vital to consider the patients' expectations and preferences adequately. Based on a comprehensive review of the literature and our own clinical experiences, subtotal cystectomy followed by bladder augmentation is considered a safe and effective surgical option. This stepwise and tailored therapeutic approach aims to optimize patients' quality of life by specifically targeting Hunner-type IC.

Treatment of Low-grade Intermediate-risk Nonmuscle-invasive Bladder Cancer With UGN-102 ± Transurethral Resection of Bladder Tumor Compared to Transurethral Resection of Bladder Tumor Monotherapy: A Randomized, Controlled, Phase 3 Trial (ATLAS)

PURPOSE

Low-grade intermediate-risk nonmuscle-invasive bladder cancer is a chronic illness commonly treated by repetitive transurethral resection of bladder tumor. We compared the efficacy and safety of intravesical chemoablation with UGN-102 (a reverse thermal gel containing mitomycin), with or without subsequent transurethral resection of bladder tumor, to transurethral resection of bladder tumor alone in patients with low-grade intermediate-risk nonmuscle-invasive bladder cancer.

MATERIALS AND METHODS

This prospective, randomized, phase 3 trial recruited patients with new or recurrent low-grade intermediate-risk nonmuscle-invasive bladder cancer to receive initial treatment with either UGN-102 once weekly for 6 weeks or transurethral resection of bladder tumor. Patients were followed quarterly by endoscopy, cytology, and for-cause biopsy. The primary end point was disease-free survival. All patients were followed for adverse events.

RESULTS

Trial enrollment was halted by the sponsor to pursue an alternative development strategy after 282 of a planned 632 patients were randomized to UGN-102 ± subsequent transurethral resection of bladder tumor (n=142) or transurethral resection of bladder tumor monotherapy (n=140), rendering the trial underpowered to perform hypothesis testing. Patients were predominantly male and ≥65 years of age. Tumor-free complete response 3 months after initial treatment was achieved by 92 patients (65%) who received UGN-102 and 89 patients (64%) treated by transurethral resection of bladder tumor. The estimated probability of disease-free survival 15 months after randomization was 72% for UGN-102 ± transurethral resection of bladder tumor and 50% for transurethral resection of bladder tumor (hazard ratio 0.45). The most common adverse events (incidence ≥10%) in the UGN-102 group were dysuria, micturition urgency, nocturia, and pollakiuria.

CONCLUSIONS

Primary, nonsurgical chemoablation with UGN-102 for the management of low-grade intermediate-risk nonmuscle-invasive bladder cancer offers a potential therapeutic alternative to immediate transurethral resection of bladder tumor monotherapy and warrants further investigation.

Heat treatment for giant cell tumors of bone: A systematic review

This systematic review evaluates the effects of heat treatments in de novo, residual and recurrent giant cell tumors of bone (GCTB). Studies were eligible for inclusion if one of the following treatments was administered: radiofrequency ablation (RFA), microwave ablation, argon cauterization, electrocauterization and hot liquid treatment. The primary outcome was recurrence. Secondary outcomes were complications, pain, function, and quality of life. Recurrence rates for microwave ablation as an adjuvant to intralesional curettage were 0%, 4% and 10% (3 retrospective single-group studies); for argon cauterization 4%, 8% and 26% (3 cohort studies); electrocauterization 0% to 33% (8 cohort studies); and hot liquid 9.5% and 24% (2 cohort studies). Follow-up was generally ≥24 months. Data on pain, function and quality of life were scarce. Complications included infection and secondary osteoarthritis. Current evidence does not demonstrate or exclude an effect of heat treatments on recurrence in GCTB. Further research should objectify if (subgroups of) patients benefit from these treatments.

Effectiveness and Safety of Percutaneous Treatment in Lesions Suggestive of Thyroid Cancer (Bethesda V and VI-T1aN0M0) Compared to Surgical Treatment: Systematic Review and Meta-Analysis

INTRODUCTION

Thyroid nodules are common entities, with 5% malignancy. Differentiated thyroid cancer represents 90% of thyroid malignancies, with papillary carcinoma being the most common. Management is generally surgical; among its complications are injury to the recurrent laryngeal and superior laryngeal nerve, causing hoarseness, postsurgical hypoparathyroidism, hypothyroidism, and pain. Other noninvasive percutaneous interventions of thermal ablation such as microwave, radiofrequency, or laser incur lower costs and could be an option for treatment.

OBJECTIVE

To determine the effectiveness and safety of thermal ablation in lesions suspected of thyroid cancer (Bethesda V and VI/T1aN0M0) compared to surgical treatment.

METHODS

Systematic review/meta-analysis of observational studies and clinical trials. Database search includes MEDLINE/PUBMED, Embase, Scopus, Scielo, and BVS/LILACS. Studies on patients over 18 years of age with lesions suspicious of thyroid cancer were included.

RESULTS

A total of 10 studies were obtained, with 2939 patients: 1468 subjected to thermal ablation and 1471 to surgery. Regarding effectiveness, no differences were found in local recurrence [relative risk (RR) 1.17 (95% CI 0.69-1.99)] and cervical lymph node metastasis [RR 0.76 (95% CI 0.43-1.36)]. Regarding safety, infection [RR 0.29 (95% CI 0.05-1.74)], hematoma [RR 0.57 (95% CI 0.17-1.94)], and transient hoarseness [RR 0.77 (95% CI 0.39-1.51)] were evaluated, without difference. However, permanent hoarseness had significant differences in favor of thermal ablation [RR 0.29 (95% CI 0.11-0.75)].

CONCLUSIONS

Thermal ablation for the treatment of T1aN0M0 papillary thyroid carcinoma is equally effective when compared to surgical techniques and offers a better safety profile, particularly in permanent hoarseness.

Multi-Probe RFA vs. Single-Probe MWA in an Ex Vivo Bovine Liver Model: Comparison of Volume and Shape of Coagulation Zones

OBJECTIVES

To compare the volumes and shapes of the coagulation zone (CZ) of a multi-probe RFA system (three RFA electrodes) and a single-probe MWA system from the same vendor in an ex vivo bovine liver model.

MATERIAL & METHODS

A total of 48 CZs were obtained in bovine liver specimens with three different ablation system configurations (single-probe MWA vs. multi-probe RFA with 20 mm inter-probe distance [confluent CZ] vs. multi-probe RFA with 50 mm inter-probe distance [three individual CZs]) at 4, 6, 8, and 10 min ablation time using a fixed ablation protocol. Ablation diameters were measured and ellipticity indices (EIs) and volumes calculated. Calculations for all systems/configurations were compared.

RESULTS

Volumes and diameters increased with ablation time for all configurations. At 4 and 6 min ablation time volumes obtained with the RFA 50 mm setup, and at 8 and 10 min with the RFA 20 mm setup were the largest at 26.5 ± 4.1 mL, 38.1 ± 5.8 mL, 46.3 ± 4.9 mL, 48.4 ± 7.3 mL, respectively. The single-probe MWA could not reach the volumes of the RFA setups for any of the ablation times evaluated. EI were very similar and almost round for RFA 20 mm and single-probe MWA, and differed significantly to the more ovoid ones for the RFA 50 mm configuration.

CONCLUSIONS

The multi-probe RFA system employing three electrodes achieved significantly larger ablation volumes in both configurations (confluent CZ and three individual CZs) per time as compared with a single-probe MWA system in this ex vivo bovine liver model.

Immunomodulatory Effects of Endoscopic Ultrasound-Guided Thermal Ablation in Patients with Pancreatic Ductal Adenocarcinoma

Immunological consequences of endoscopic ultrasound (EUS)-local thermal ablation (LTA) for pancreatic ductal adenocarcinoma (PDAC) have not been extensively assessed. We aimed to explore EUS-LTA effects on the systemic immune response in PDAC. Peripheral blood was collected from 10 treatment-naïve patients with borderline resectable and locally advanced PDAC, randomly allocated to Nab-paclitaxel plus Gemcitabine chemotherapy (CT-arm, n = 5) or EUS-LTA with HybridTherm Probe plus CT (HTP + CT-arm, n = 5). Twenty healthy donors were included as controls. Flow-cytometry and multiplex assays were used to profile immune cell subsets and measure serum cytokines/chemokines, respectively. At baseline, PDAC patients showed increased circulating monocytes and lower circulating lymphocytes and CD19+ B cells counts compared to healthy controls. After 4 months, CT induced decrease of B regulatory cells, CD4+ cytotoxic T cells and IL-1β. The addition of EUS-HTP to CT selectively decreased the serum levels of APRIL/TNFSF13 as well as T regulatory cells, total, classic and inflammatory monocytes. Serum levels of APRIL/TNFSF13 and total, classic and inflammatory monocytes counts at baseline were associated with worse overall survival. EUS-HTP has the potential to selectively impact on immune cells and cytokines associated with poor outcomes in PDAC.

Evaluation of Outcomes Following Focal Ablative Therapy for Treatment of Localized Clinically Significant Prostate Cancer in Patients >70 Years: A Multi-institute, Multi-energy 15-Year Experience

PURPOSE

In older patients who do not wish to undergo watchful waiting, focal therapy could be an alternative to the more morbid radical treatment. We evaluated the role of focal therapy in patients 70 years and older as an alternative management modality.

MATERIALS AND METHODS

A total of 649 patients across 11 UK sites receiving focal high-intensity focused ultrasound or cryotherapy between June 2006 and July 2020 reported within the UK-based HEAT (HIFU Evaluation and Assessment of Treatment) and ICE (International Cryotherapy Evaluation) registries were evaluated. Primary outcome was failure-free survival, defined by need for more than 1 focal reablation, progression to radical treatment, development of metastases, need for systemic treatment, or prostate cancer-specific death. This was compared to the failure-free survival in patients undergoing radical treatment via a propensity score weighted analysis.

RESULTS

Median age was 74 years (IQR: 72, 77) and median follow-up 24 months (IQR: 12, 41). Sixty percent had intermediate-risk disease and 35% high-risk disease. A total of 113 patients (17%) required further treatment. Sixteen had radical treatment and 44 required systemic treatment. Failure-free survival was 82% (95% CI: 76%-87%) at 5 years. Comparing patients who had radical therapy to those who had focal therapy, 5-year failure-free survival was 96% (95% CI: 93%-100%) and 82% (95% CI: 75%-91%) respectively (P < .001). Ninety-three percent of those in the radical treatment arm had received radiotherapy as their primary treatment with its associated use of androgen deprivation therapy, thereby leading to potential overestimation of treatment success in the radical treatment arm, especially given the similar metastases-free and overall survival rates seen.

CONCLUSIONS

We propose focal therapy to be an effective management option for the older or comorbid patient who is unsuitable for or not willing to undergo radical treatment.

Locoregional treatment for colorectal liver metastases aiming for precision medicine

In patients with colorectal liver metastases (CLM), surgery is potentially curative. The use of novel surgical techniques and complementary percutaneous ablation allows for curative-intent treatment even in marginally resectable cases. Resection is used as part of a multidisciplinary approach, which for nearly all patients will include perioperative chemotherapy. Small CLM can be treated with parenchymal-sparing hepatectomy (PSH) and/or ablation. For small CLM, PSH results in better survival and higher rates of resectability of recurrent CLM than non-PSH. For patients with extensive bilateral distribution of CLM, two-stage hepatectomy or fast-track two-stage hepatectomy is effective. Our increasing knowledge of genetic alterations allows us to use them as prognostic factors alongside traditional risk factors (e.g. tumor diameter and tumor number) to select patients with CLM for resection and guide surveillance after resection. Alteration in RAS family genes (hereafter referred to as "RAS alteration") is an important negative prognostic factor, as are alterations in the TP53, SMAD4, FBXW7, and BRAF genes. However, APC alteration appears to improve prognosis. RAS alteration, increased number and diameter of CLM, and primary lymph node metastasis are well-known risk factors for recurrence after CLM resection. In patients free of recurrence 2 y after CLM resection, only RAS alteration is associated with recurrence. Thus, surveillance intensity can be stratified by RAS alteration status after 2 y. Novel diagnostic instruments and tools, such as circulating tumor DNA, may lead to further evolution of patient selection, prognostication, and treatment algorithms for CLM.

Efficacy of fusion imaging for immediate post-ablation assessment of malignant liver neoplasms: A systematic review

BACKGROUND

Percutaneous thermal ablation has become the preferred therapeutic treatment option for liver cancers that cannot be resected. Since ablative zone tissue changes over time, it becomes challenging to determine therapy effectiveness over an extended period. Thus, an immediate post-procedural evaluation of the ablation zone is crucial, as it could influence the need for a second-look treatment or follow-up plan. Assessing treatment response immediately after ablation is essential to attain favorable outcomes. This study examines the efficacy of image fusion strategies immediately post-ablation in liver neoplasms to determine therapeutic response.

METHODOLOGY

A comprehensive systematic search using PRISMA methodology was conducted using EMBASE, MEDLINE (via PUBMED), and Cochrane Library Central Registry electronic databases to identify articles that assessed the immediate post-ablation response in malignant hepatic tumors with fusion imaging (FI) systems. The data were retrieved on relevant clinical characteristics, including population demographics, pre-intervention clinical history, lesion characteristics, and intervention type. For the outcome metrics, variables such as average fusion time, intervention metrics, technical success rate, ablative safety margin, supplementary ablation rate, technical efficacy rate, LTP rates, and reported complications were extracted.

RESULTS

Twenty-two studies were included for review after fulfilling the study eligibility criteria. FI's immediate technical success rate ranged from 81.3% to 100% in 17/22 studies. In 16/22 studies, the ablative safety margin was assessed immediately after ablation. Supplementary ablation was performed in 9 studies following immediate evaluation by FI. In 15/22 studies, the technical effectiveness rates during the first follow-up varied from 89.3% to 100%.

CONCLUSION

Based on the studies included, we found that FI can accurately determine the immediate therapeutic response in liver cancer ablation image fusion and could be a feasible intraprocedural tool for determining short-term post-ablation outcomes in unresectable liver neoplasms. There are some technical challenges that limit the widespread adoption of FI techniques. Large-scale randomized trials are warranted to improve on existing protocols. Future research should emphasize improving FI's technological capabilities and clinical applicability to a broader range of tumor types and ablation procedures.

The Autonomic Coumel Triangle: A New Way to Define the Fascinating Relationship between Atrial Fibrillation and the Autonomic Nervous System

Arrhythmogenic substrate, modulating factors, and triggering factors (the so-called Coumel's triangle concept) play a primary role in atrial fibrillation (AF) pathophysiology. Several years have elapsed since Coumel and co-workers advanced the concept of the relevance of autonomic nervous system (ANS) influences on atrial cells' electrophysiological characteristics. The ANS is not only associated with cardiac rhythm regulation but also exerts an important role in the triggering and maintenance of atrial fibrillation. This review aims to describe in detail the autonomic mechanisms involved in the pathophysiology of atrial fibrillation (AF), starting from the hypothesis of an "Autonomic Coumel Triangle" that stems from the condition of the fundamental role played by the ANS in all phases of the pathophysiology of AF. In this article, we provide updated information on the biomolecular mechanisms of the ANS role in Coumel's triangle, with the molecular pathways of cardiac autonomic neurotransmission, both adrenergic and cholinergic, and the interplay between the ANS and cardiomyocytes' action potential. The heterogeneity of the clinical spectrum of the ANS and AF, with the ANS playing a relevant role in situations that may promote the initiation and maintenance of AF, is highlighted. We also report on drug, biological, and gene therapy as well as interventional therapy. On the basis of the evidence reviewed, we propose that one should speak of an "Autonomic Coumel's Triangle" instead of simply "Coumel's Triangle".

Clinical outcomes of ultrasound-guided radiofrequency ablation for solitary T1N0M0 papillary thyroid carcinoma: A retrospective study with more than 5 years of follow-up

BACKGROUND

Ultrasound-guided radiofrequency ablation (RFA) has been used in patients with papillary thyroid carcinoma (PTC) who refuse surgery or active surveillance. However, the long-term outcomes are still limited. This study aimed to evaluate the clinical outcomes of RFA for solitary T1N0M0 PTC in a large cohort over a more than 5-year follow-up period.

METHODS

This retrospective study included 358 patients with solitary T1N0M0 PTC who were treated with RFA and followed for at least 5 years. The bipolar RFA procedure was performed using hydrodissection technique, transisthmic approach, and moving-shot technique. The primary outcomes were disease progression, including lymph node metastasis (LNM), recurrent tumor, persistent tumor, and distant metastasis. The secondary outcomes were volume reduction rate, complete disappearance rate, complications, and delayed surgery.

RESULTS

During a mean follow-up period of 75.5 ± 9.7 months, the overall disease progression was 5.0%. The incidence of LNM, recurrent tumor, and persistent tumor was 1.4%, 3.1%, and 0.6%, respectively. There were no significant differences in the disease progression (5.0% vs. 5.5%, p = 1.000), LNM (1.3% vs. 1.8%, p = .568), recurrent tumor (3.3% vs. 1.8%, p = .872), persistent tumors (0.3% vs. 1.8%, p = .284), and 5-year recurrence-free survival rates (95.4% vs. 96.4%, p = .785) in the T1a and T1b groups. Volume reduction rate was 100.0 ± 0.3%, with 96.9% of tumors disappearing. No complications occurred. No patients underwent delayed surgery because of anxiety.

CONCLUSIONS

RFA is an effective and safe alternative for patients with T1N0M0 PTC and can offer a minimally invasive curative option for patients who refuse surgery or active surveillance.

PLAIN LANGUAGE SUMMARY

During a mean follow-up period of 75.5 ± 9.7 months, the overall papillary thyroid carcinoma disease progression was 5.0%. The volume reduction rate was 100.0 ± 0.3%, with 96.9% of tumors disappearing. The T1a and T1b groups had similar incidence of disease progression and 5-year recurrence-free survival rates. No patients experienced complications or underwent delayed surgery because of anxiety.

Sex-based differences in atrial fibrillation ablation adverse events

OBJECTIVE

Older, relatively small studies identified female sex as a risk factor for adverse events after catheter ablation for atrial fibrillation (AF). We aimed to assess contemporary sex-based differences in baseline and procedural characteristics, adverse events, and quality of life among adults undergoing catheter ablation for AF.

METHODS

In this observational cohort study, we evaluated those enrolled in the National Cardiovascular Data Registry AFib Ablation Registry between January 2016 and September 2020. Using logistic regression, we analysed the association between patient sex and in-hospital adverse events.

RESULTS

Among 58 960 adults (34.6% women) from 150 centres undergoing AF ablation by 706 physicians, women were older (68 vs 64 years, p<0.001), had more comorbidities, and had lower AF-related quality of life at the time of ablation (mean Atrial Fibrillation Effect on QualiTy-of-life Questionnaire) score: 51.8 vs 62.2, p<0.001). Women had a higher risk of hospitalisation >1 day (adjusted OR (aOR) 1.41 (95% CI 1.33 to 1.49)), major adverse event (aOR 1.60 (95% CI 1.33 to 1.92)) and any adverse event (aOR 1.57 (95% CI 1.41 to 1.75)). Women had a higher risk of bradycardia requiring pacemaker, phrenic nerve damage, pericardial effusion, bleeding and vascular injury, but had no differences in death or acute pulmonary vein isolation.

CONCLUSIONS

Among almost 60 000 patients in the largest prospective registry of AF ablation procedures, female sex was independently associated with a higher risk of hospitalisation >1 day, adverse events, and reduced quality of life, although there were no differences in death or acute pulmonary vein isolation.

Utility of Magnetic Resonance Imaging for Localizing Prostate Cancer Near the Urethra in Men Who Are Candidates for Focal Gland Ablation

PURPOSE

Given that treatment near the urethra is often limited to reduce side effects, in this study we aim to determine whether prostate MRI can accurately identify the distance of prostate cancer to the urethra in a cohort of men who were potential candidates for focal gland ablation.

MATERIALS AND METHODS

A single-institution analysis was performed of men who underwent MRI, targeted biopsy, and radical prostatectomy from July 2012 to April 2021. Men who were candidates for focal gland ablation were identified. The ability of MRI to identify prostate cancer within 5 mm of the prostatic urethra as confirmed on whole-mount pathology was assessed. Multivariate regression was utilized to determine characteristics associated with prostate cancer within 5 mm of the urethra on whole-mount pathology.

RESULTS

In 48 out of 67 men (72%), the tumor was within 5 mm of the urethra on whole-mount pathology. MRI was concordant with whole-mount pathology in 49 out of 67 men (73%). The sensitivity of MRI for identifying cancer within 5 mm of the urethra was 77% (65%-89%) and the specificity was 63% (42%-89%). The positive predictive value was 84% (range 73%-95%) and negative predictive value was 52% (32%-73%). In adjusted analysis, PSA density and Prostate Imaging-Reporting and Data System were not significantly associated with having prostate cancer within close proximity of the urethra.

CONCLUSIONS

A significant number of men who are potential candidates for focal gland ablation have cancer within close proximity to the urethra that could serve as a significant source of in-field recurrence. The sensitivity of MRI for identifying these lesions is 77% and can be used to further improve patient selection for focal gland ablation.

Patient Preferences for Pharmaceutical and Device-Based Treatments for Uncontrolled Hypertension: Discrete Choice Experiment

BACKGROUND

Discrete choice experiment is a survey method used to understand how individuals make decisions and to quantify the relative importance of features. Using discrete choice experiment methods, we quantified patient benefit-risk preferences for hypertension treatments, including pharmaceutical and interventional treatments, like renal denervation.

METHODS

Respondents from the United States with physician-confirmed uncontrolled hypertension selected between treatments involving a procedure or pills, using a structured survey. Treatment features included interventional, noninterventional, or no hypertension treatment; number of daily blood pressure (BP) pills; expected reduction in office systolic BP; duration of effect; and risks of drug side effects, access site pain, or vascular injury. The results of a random-parameters logit model were used to estimate the importance of each treatment attribute.

RESULTS

Among 400 patients completing the survey between 2020 and 2021, demographics included: 52% women, mean age 59.2±13.0 years, systolic BP 155.1±12.3 mm Hg, and 1.8±0.9 prescribed antihypertensive medications. Reduction in office systolic BP was the most important treatment attribute. The remaining attributes, in decreasing order, were duration of effect, whether treatment was interventional, number of daily pills, risk of vascular injury, and risk of drug side effects. Risk of access site pain did not influence choice. In general, respondents preferred noninterventional over interventional treatments, yet only a 2.3 mm Hg reduction in office systolic BP was required to offset this preference. Small reductions in office systolic BP would offset risks of vascular injury or drug side effects. At least a 20% risk of vascular injury or drug side effects would be tolerated in exchange for improved BP.

CONCLUSIONS

Reduction in systolic BP was identified as the most important driver of patient treatment preference, while treatment-related risks had less influence. The results indicate that respondents would accept interventional treatments in exchange for modest reductions in systolic BP compared with those observed in renal denervation trials.

Cancer-specific Mortality After Cryoablation vs Heat-based Thermal Ablation in T1a Renal Cell Carcinoma

PURPOSE

Guidelines suggest less favorable cancer control outcomes for local tumor destruction in T1a renal cell carcinoma patients with tumor size 3.1-4 cm. We compared cancer-specific mortality between cryoablation vs heat-based thermal ablation in patients with tumor size 3.1-4 cm, as well as in patients with tumor size ≤3 cm.

MATERIALS AND METHODS

Within the Surveillance, Epidemiology, and End Results database (2004-2018), we identified patients with clinical T1a stage renal cell carcinoma treated with cryoablation or heat-based thermal ablation. After up to 2:1 ratio propensity score matching between patients treated with cryoablation vs heat-based thermal ablation, we addressed cancer-specific mortality relying on competing risks regression models, adjusted for other-cause mortality and other covariates (age, tumor size, tumor grade, and histological subtype).

RESULTS

Of 1,468 assessable patients with tumor size 3.1-4 cm, 1,080 vs 388 were treated with cryoablation vs heat-based thermal ablation, respectively. After up to 2:1 propensity score matching that resulted in 757 cryoablations vs 388 heat-based thermal ablations, in multivariable competing risks regression models, heat-based thermal ablation was associated with higher cancer-specific mortality (HR:2.02, P < .001), relative to cryoablation. Of 4,468 assessable patients with tumor size ≤3 cm, 3,354 vs 1,114 were treated with cryoablation vs heat-based thermal ablation, respectively. After up to 2:1 propensity score matching that resulted in 2,217 cryoablations vs 1,114 heat-based thermal ablations, in multivariable competing risks regression models, heat-based thermal ablation was not associated with higher cancer-specific mortality (HR:1.13, P = .5) relative to cryoablation.

CONCLUSIONS

Our findings corroborated that in cT1a patients with tumor size 3.1-4 cm, cancer-specific mortality is twofold higher after heat-based thermal ablation vs cryoablation. Conversely, in patients with tumor size ≤3 cm either ablation technique is equally valid. These findings should be considered at clinical decision making and informed consent.

Coronary Arterial Spasm During Pulsed Field Ablation to Treat Atrial Fibrillation

BACKGROUND

Pulsed field ablation (PFA) has a unique safety profile when used to treat atrial fibrillation, largely related to its preferentiality for myocardial tissue ablation, in particular, esophageal sparing. A pentaspline catheter was the first such PFA system studied clinically for atrial fibrillation ablation; in these initial regulatory trials, the catheter was used for pulmonary vein isolation and left atrial posterior wall ablation. Since its regulatory approval in Europe, in clinical practice, physicians have ablated beyond pulmonary vein isolation and left atrial posterior wall ablation to expanded lesion sets in closer proximity to coronary arteries. This is an unstudied important issue because preclinical and clinical data have raised the potential for coronary arterial spasm. Herein, we studied the vasospastic potential of PFA lesion sets, both remote from and adjacent to coronary arteries.

METHODS

During routine atrial fibrillation ablation using the pentaspline PFA catheter, coronary angiography was performed before, during, and after pulsed field applications. The lesion sets studied included: (1) those remote from the coronary arteries such as pulmonary vein isolation (n=25 patients) and left atrial posterior wall ablation (n=5), and (2) ablation of the cavotricuspid isthmus (n=20) that is situated adjacent to the right coronary artery.

RESULTS

During pulmonary vein isolation and left atrial posterior wall ablation, coronary spasm did not occur, but cavotricuspid isthmus ablation provoked severe subtotal vasospasm in 5 of 5 (100%) consecutive patients, and this was relieved by intracoronary nitroglycerin in 5.5±3.5 minutes. ST-segment elevation was not observed. However, no patient (0%, P=0.004) had severe spasm if first administered parenteral nitroglycerin, either intracoronary (n=5) or intravenous (n=10), before treatment.

CONCLUSIONS

Coronary vasospasm was not provoked during PFA at locations remote from coronary arteries, but when the energy is delivered adjacent to a coronary artery, PFA routinely provokes subclinical vasospasm. This phenomenon is attenuated by nitroglycerin, administered either post hoc to treat spasm or as prophylaxis.

Substrate Ablation by Multivein, Multiballoon Coronary Venous Ethanol for Refractory Ventricular Tachycardia in Structural Heart Disease

BACKGROUND

Ablation of ventricular tachycardia (VT) in the setting of structural heart disease often requires extensive substrate elimination that is not always achievable by endocardial radiofrequency ablation. Epicardial ablation is not always feasible. Case reports suggest that venous ethanol ablation (VEA) through a multiballoon, multivein approach can lead to effective substrate ablation, but large data sets are lacking.

METHODS

VEA was performed in 44 consecutive patients with ablation-refractory VT (ischemic, n=21; sarcoid, n=3; Chagas, n=2; idiopathic, n=18). Targeted veins were selected by mapping coronary veins on the epicardial aspect of endocardial scar (identified by bipolar voltage <1.5 mV), using venography and signal recording with a 2F octapolar catheter or by guidewire unipolar signals. Epicardial mapping was performed in 15 patients. Vein segments in the epicardial aspect of VT substrates were treated with double-balloon VEA by blocking flow with 1 balloon while injecting ethanol through the lumen of the second balloon, forcing (and restricting) ethanol between balloons. Multiple balloon deployments and multiple veins were used as needed. In 22 patients, late gadolinium enhancement cardiac magnetic resonance imaged the VEA scar and its evolution.

RESULTS

Median ethanol delivered was 8.75 (interquartile range, 4.5-13) mL. Injected veins included interventricular vein (6), diagonal (5), septal (12), lateral (16), posterolateral (7), and middle cardiac vein (8), covering the entire range of left ventricular locations. Multiple veins were targeted in 14 patients. Ablated areas were visualized intraprocedurally as increased echogenicity on intracardiac echocardiography and incorporated into 3-dimensional maps. After VEA, vein and epicardial ablation maps showed elimination of abnormal electrograms of the VT substrate. Intracardiac echocardiography demonstrated increased intramural echogenicity at the targeted region of the 3-dimensional maps. At 1 year of follow-up, median of 314 (interquartile range, 198-453) days of follow-up, VT recurrence occurred in 7 patients, for a success of 84.1%.

CONCLUSIONS

Multiballoon, multivein intramural ablation by VEA can provide effective substrate ablation in patients with ablation-refractory VT in the setting of structural heart disease over a broad range of left ventricular locations.

CT-Guided Radiofrequency Thermal Ablation for the Treatment of Atypical, Early-Onset Osteoid Osteoma in Children Younger than 4 Years Old: Single-Institution Experience and Literature Review

The aim of our study is to report our experience on CT-guided radiofrequency ablation (RFA) for osteoid osteoma (OO) in children under 4 years of age and to review the literature regarding this atypical, early onset of the disease. We retrospectively reviewed the clinical and radiological records of the patients treated with CT-guided RFA for OO at our institution (2006−2021), including those under 4 years of age. Data regarding technical success, clinical success, and biopsy diagnostic yield were collected. Moreover, we performed a literature review including previous articles on early-onset OO. We found only 12 patients that were under 4 years of age (12/842−1.4%) at the time of RFA treatment: 4 F and 8 M, mean age at the time of the treatment 35.3 months (range 22−46 months). The mean follow-up was 22.8 months (range 6−96 months). Technical success was achieved in all cases (12/12). In all patients (12/12), a complete remission of the pain symptoms was achieved at clinical follow-up controls. No recurrence of pain or complications were documented. The histopathological diagnosis was confirmed in 4 patients (4/12−33.3%). Moreover, we found another 9 articles in the literature with a main focus on early-onset OO (<4 years old), with a total of 12 patients included; 6 of those patients (6/12−50%) were treated with CT-guided RFA, with success reported 5 cases (5/6−83.3%). Our series of cases treated at a single institution, together with the existing data from the literature, confirms that CT-guided RFA is effective and safe for the treatment of osteoid osteoma, even in atypical, early onset in children under 4 years of age.

Endoscopic ablation therapy for the pancreatic neoplasms

Recently, endoscopic ultrasound (EUS)-guided ablation therapy has been reported as a less invasive therapy for patients with pancreatic neoplasms. Some ablation techniques, including injective ablation (using ethanol or other ablative agents), radiofrequency ablation (RFA), photodynamic therapy, and laser ablation, have been described in the literature. Among these, injective ablation and RFA are more frequently used for treating pancreatic neoplasms. Few studies have evaluated the effectiveness of EUS-guided ethanol ablation (EUS-EA) for potentially malignant solid neoplasms (neuroendocrine neoplasms or solid pseudopapillary neoplasms) and have reported a complete response (CR) rate of 60-80%. In addition, the CR rate after EUS-RFA for these lesions has been reported to be 55-100%, with no additional procedure-related adverse events (AEs). Regarding the amelioration of the symptoms of an insulinoma, the success rates of both the therapies were found to be excellent. Regarding complete tumor ablation, EUS-RFA appeared to be superior to EUS-EA. Although EUS-RFA has been reported as a safe treatment for pancreatic cancers, its effectiveness remains inadequate. Some studies have examined the effectiveness of EUS-guided injection ablation therapy for pancreatic cystic neoplasms (PCNs) and have reported CR rates that range from 35% to 79%. Alcohol-free chemotherapeutic agent ablation appears to be effective, with a low risk of AEs. However, studies on the effectiveness of EUS-RFA for PCNs are limited. In the future, EUS-guided ablation therapy could become a more widely used approach for potentially malignant and malignant pancreatic lesions.

Artery-first microwave ablation in the treatment of benign thyroid nodules

BACKGROUND

Microwave ablation (MWA) is a safe and effective procedure for the treatment of benign thyroid nodules. The MWA causes progressive nodule shrinkage as well as the improvement of the symptoms and cosmesis. Some basic techniques have been described to further increase the efficacy and safety of this procedure.

OBJECTIVES

To evaluate the efficacy of artery-first MWA as an advanced technique in the treatment of benign thyroid nodules.

MATERIAL AND METHODS

A total of 40 patients treated with MWA were enrolled in the study. Nineteen patients who underwent artery-first MWA were selected for the study group and 21 patients who underwent MWA alone were included in the control group. Nodular vascularization was assessed using a new Doppler technique (Superb Microvascular Imaging (SMI)) and characterized using a 3-point scale. All patients were evaluated in terms of volume, symptoms, cosmetic scores, and laboratory findings before the procedure as well as 3 months (early-term follow-up) and 6 months (intermediate-term follow-up) after the procedure.

RESULTS

Both groups were comparable with respect to the baseline volume (p = 0.135). Nevertheless, the nodular volume reduction rate was significantly different at 3-month follow-up (study group: 56.97 ±11.39%, control group: 47.07 ±7.93%; p = 0.003) and 6-month follow-up (study group: 78.38 ±8.91%, control group: 69.54 ±9.41%; p = 0.004). In both groups, cosmetic and symptom scores decreased progressively (p < 0.005) and there were no major complications. Thyroid hormones and antibodies were within normal limits before the procedure, and no significant change was observed during follow-up after the ablation.

CONCLUSIONS

The artery-first MWA technique can be used in the treatment of benign thyroid nodules as a method of increasing the effectiveness of MWA.

MR-Guided Microwave Ablation for Lung Malignant Tumor: A Single Center Prospective Study

Objectives

To prospectively investigate the feasibility and efficacy of MRI-guided MWA for lung malignant tumor in our single center.

Materials and Methods

22 patients [mean age, 56.86 ± 13.05(23–73)years] with 23 malignant lung tumors were enrolled in the study. 21 patients had a single lesion and 1 patient had 2 lesions in the ipsilateral lung. The average maximum diameter of the lesion was 1.26 ± 0.65 (0.50-2.58)cm. Percutaneous MWA was guided by 1.5T MRI scanner using a MR-compatible microwave antenna to the target the lung lesions and ablation area was monitored intraoperatively by using a shielded MR-compatible microwave device and then follow-up.

Results

All patients were successfully treated under MR-guided MWA for lung tumors. Average operation time was 72.21 ± 24.99 (36–158) mins. T2WI signal intensity of the lesion gradually decreased over the course of MWA. The center of the ablated zones showed a short T1 and short T2 signals with the ring-like of long T1 and long T2 signals surrounded after immediately evaluation. No serious complications occurred. The average follow-up period was 12.89 ± 4.33 (2.0-19.6) months. Local recurrence occurred in one patient, representing a technical efficacy of 95.5% (21/22).

Conclusion

Magnetic resonance-guided microwave ablation for lung malignant tumor was feasible and demonstrated unique advantages in efficacy evaluation.

Contrast-enhanced ultrasound is a reliable and reproducible assessment of necrotic ablated volume after radiofrequency ablation for benign thyroid nodules: a retrospective study

PURPOSE

To investigate the intra- and inter-observer reliability and agreement of contrast-enhanced ultrasound (CEUS) in measuring ablated volume (Va) after radiofrequency ablation (RFA) for benign thyroid nodules.

MATERIALS

This retrospective study evaluated 65 patients with 74 benign thyroid nodules who underwent RFA. Patients were followed up at 1, 3, 6, and 12 months and every 12 months thereafter. Two independent observers measured the Va using CEUS during the same follow-up visit. The intra- and inter-observer reliability was assessed using intraclass correlation coefficient (ICC) with 95% confidence interval. The Bland-Altman analysis was used to evaluate the inter-observer agreement, which was expressed as a mean difference with 95% limit of agreement (LOA).

RESULTS

No significant difference was found in Va measurements by the two observers with a mean follow-up time of 41.17 ± 16.80 months (all p > 0.05). The intra- and inter-observer reliability were both excellent (ICC >0.90) at each follow-up period. The 95% LOA became wider over the follow-up period. The smallest 95% LOA was found at 1 month with a LOA from 0.8117 to 1.122, and the largest 95% LOA was from 0.5694 to 1.343 at 36 months.

CONCLUSIONS

CEUS could provide a reliable and reproducible assessment of Va after RFA for benign thyroid nodules. In clinical post-ablation follow-up, the irregular morphology of ablated area and the variation by different observers could not affect the assessment of Va by CEUS.

3D Quantitative Ablation Margins for Prediction of Ablation Site Recurrence After Stereotactic Image-Guided Microwave Ablation of Colorectal Liver Metastases: A Multicenter Study

Background

Three-dimensional (3D) volumetric ablation margin assessment after thermal ablation of liver tumors using software has been described, but its predictive value on treatment efficacy when accounting for other factors known to correlate ablation site recurrence (ASR) remains unknown.

Purpose

To investigate 3D quantitative ablation margins (3D-QAMs) as an algorithm to predict ASR within 1 year after stereotactic microwave ablation (SMWA) for colorectal liver metastases (CRLM).

Materials and Methods

Sixty-five tumors in 47 patients from a prospective multicenter study of patients undergoing SMWA for CRLM were included in this retrospective 3D-QAM analysis. Using a previously developed algorithm, 3D-QAM defined as the distribution of tumor to ablation surface distances was assessed in co-registered pre- and post-ablation CT scans. The discriminatory power and optimal cutoff values for 3D-QAM were assessed using receiver operating characteristic (ROC) curves. Multivariable logistic regression analysis using generalized estimating equations was applied to investigate the impact of various 3D-QAM outputs on 1-year ASR while accounting for other known influencing factors.

Results

Ten of the 65 (15.4%) tumors included for 3D-QAM analysis developed ASR. ROC analyses identified i) 3D-QAM <1 mm for >23% of the tumor surface, ii) 3D-QAM <5 mm for >45%, and iii) the minimal ablation margin (MAM) as the 3D-QAM outputs with optimal discriminatory qualities. The multivariable regression model without 3D-QAM yielded tumor diameter and KRAS mutation as 1-year ASR predictors. When adding 3D-QAM, this factor became the main predictor of 1-year ASR [odds ratio (OR) 21.67 (CI 2.48, 165.21) if defined as >23% <1 mm; OR 0.52 (CI 0.29, 0.95) if defined as MAM].

Conclusions

3D-QAM allows objectifiable and standardized assessment of tumor coverage by the ablation zone after SMWA. Our data shows that 3D-QAM represents the most important factor predicting ASR within 1 year after SMWA of CRLM.

Cardiac stereotactic ablative radiotherapy for control of refractory ventricular tachycardia: initial UK multicentre experience

Background

Options for patients with ventricular tachycardia (VT) refractory to antiarrhythmic drugs and/or catheter ablation remain limited. Stereotactic radiotherapy has been described as a novel treatment option.

Methods

Seven patients with recurrent refractory VT, deemed high risk for either first time or redo invasive catheter ablation, were treated across three UK centres with non-invasive cardiac stereotactic ablative radiotherapy (SABR). Prior catheter ablation data and non-invasive mapping were combined with cross-sectional imaging to generate radiotherapy plans with aim to deliver a single 25 Gy treatment. Shared planning and treatment guidelines and prospective peer review were used.

Results

Acute suppression of VT was seen in all seven patients. For five patients with at least 6 months follow-up, overall reduction in VT burden was 85%. No high-grade radiotherapy treatment-related side effects were documented. Three deaths (two early, one late) occurred due to heart failure.

Conclusions

Cardiac SABR showed reasonable VT suppression in a high-risk population where conventional treatment had failed.

Can local ablative techniques replace surgery for locally advanced pancreatic cancer?

In the treatment of pancreatic ductal adenocarcinoma (PDAC) the best chance at long term survival or cure has to date always included the complete surgical removal of the tumor. However, locally advanced pancreatic cancer (LAPC), about 25% of all newly diagnosed PDAC, is defined by its primary technical unresectability due to infiltration of visceral arteries and absence of metastasis. Induction therapies, especially FOLFIRINOX treatment, together with technical surgical advancement have increased the numbers for conversion to secondary resectability. Recent data on resections after induction therapy show promising, almost doubled survival compared to palliative treatment. Yet, around 70% of LAPC remain unresectable after induction therapy, often due to persistent local invasion. As locally ablative techniques are becoming more widely available this review examines their possible applicability to substitute for surgery in these cases which we propose to group under the new term "Inconvertible LAPC". The need for defining this novel subgroup who might benefit from ablative treatment is based on the findings in our review that high-level evidence on ablative techniques for PDAC is largely lacking and the latest effective, harmonized treatment guidelines for LAPC are not often incorporated in these studies. The "inconvertible LAPC" label requires persistent unresectability after staging and induction therapy of LAPC according to current guidelines followed by liberal indication for aggressive surgical exploration at a center equipped for extended pancreatic resections. Ideally, this specification of a new, distinct patient group will also put it in the spotlight more, hopefully prompt more trials designed to generate robust evidence and optimize transferability of study results.

Stereotactic and Robotic Minimally Invasive Thermal Ablation of Malignant Liver Tumors: A Systematic Review and Meta-Analysis

Background

Stereotactic navigation techniques aim to enhance treatment precision and safety in minimally invasive thermal ablation of liver tumors. We qualitatively reviewed and quantitatively summarized the available literature on procedural and clinical outcomes after stereotactic navigated ablation of malignant liver tumors.

Methods

A systematic literature search was performed on procedural and clinical outcomes when using stereotactic or robotic navigation for laparoscopic or percutaneous thermal ablation. The online databases Medline, Embase, and Cochrane Library were searched. Endpoints included targeting accuracy, procedural efficiency, and treatment efficacy outcomes. Meta-analysis including subgroup analyses was performed.

Results

Thirty-four studies (two randomized controlled trials, three prospective cohort studies, 29 case series) were qualitatively analyzed, and 22 studies were included for meta-analysis. Weighted average lateral targeting error was 3.7 mm (CI 3.2, 4.2), with all four comparative studies showing enhanced targeting accuracy compared to free-hand targeting. Weighted average overall complications, major complications, and mortality were 11.4% (6.7, 16.1), 3.4% (2.1, 5.1), and 0.8% (0.5, 1.3). Pooled estimates of primary technique efficacy were 94% (89, 97) if assessed at 1–6 weeks and 90% (87, 93) if assessed at 6–12 weeks post ablation, with remaining between-study heterogeneity. Primary technique efficacy was significantly enhanced in stereotactic vs. free-hand targeting, with odds ratio (OR) of 1.9 (1.2, 3.2) (n = 6 studies).

Conclusions

Advances in stereotactic navigation technologies allow highly precise and safe tumor targeting, leading to enhanced primary treatment efficacy. The use of varying definitions and terminology of safety and efficacy limits comparability among studies, highlighting the crucial need for further standardization of follow-up definitions.

Preventing atrial fibrillation by combined right isthmus ablation and cryoballoon pulmonary vein isolation in patients with typical atrial flutter: PAF-CRIOBLAF study

BACKGROUND

Although less common, typical atrial flutter shares similar pathophysiological roots with atrial fibrillation. Following successful cavo-tricuspid isthmus ablation using radiofrequency, many patients, however, develop atrial fibrillation in the mid-to-long-term. This study sought to assess whether pulmonary vein isolation conducted at the same time as cavo-tricuspid isthmus ablation would significantly modify the atrial fibrillation burden upon follow-up in patients suffering from typical atrial flutter.

METHODS

This was a multicenter randomized controlled study involving typical atrial flutter patients with history of non-predominant atrial fibrillation (1 atrial fibrillation episode only, in 67% of population) who were scheduled for cavo-tricuspid isthmus radiofrequency ablation. Patients were randomly assigned to either undergo cavo-tricuspid isthmus ablation alone or cavo-tricuspid isthmus plus pulmonary vein isolation (CTI+). Pulmonary vein isolation was performed using cryoballoon technology. An outpatient consultation with ECG and 1-week Holter monitoring was performed at 3, 6 months, 1 year, and 2 years postprocedure. The primary endpoint was atrial fibrillation recurrences lasting more than 30 s at 2 years postablation.

RESULTS

Of the patients enrolled, 36 were included in each group. At 2-year follow-up, the atrial fibrillation recurrence rate was significantly higher in the CTI vs CTI+group (25/36, 69% vs. 12/36, 33% respectively; P < .001), with similar typical atrial flutter recurrence rates. There were no differences in undesirable events, except for transient phrenic nerve palsy reported from three CTI+patients (8.3%).

CONCLUSION

Pulmonary vein isolation using cryoballoon technology was proven to significantly reduce the atrial fibrillation incidence at 2 years postcavo-tricuspid isthmus ablation.

Evolution of AquablationVR-From innovation to establishment

Technological progress is continuously improving medical care. The urological profession is well-known for further development of technical innovations and quick transfer into daily practice. Robot-assisted surgery, for example, has been part of the clinical routine in modern urological clinics for many years. In the endourological field, the implementation and further evolution of laser-based procedures have dominated research in the last decade. Recently, in 2015, the presentation of a new robot-assisted technique of waterjet-based ablation of prostate tissue raised attention in the society-the AquablationVR therapy. Aquablation therapy has been investigated within several randomized and controlled clinical trials, and-with growing experience- the technique has been modified over recent years to improve the safety of the procedure. Due to the clinical outcome, the number of hospitals performing Aquablation therapy is increasing continuously. This article provides an overview of the technique, its modifications, and the current status of evidence.

Four types of tumor progression after microwave ablation of single hepatocellular carcinoma of ≤5 cm: incidence, risk factors and clinical significance

OBJECTIVES

To evaluate the incidence, risk factors and clinical significance of four types of tumor progression (TP) after microwave ablation (MWA) of single hepatocellular carcinoma (HCC) of <5 cm.

METHODS

The data of 340 treatment-naïve, HCC patients with a single HCC of <5 cm underwent MWA between April 2012 and November 2017 were retrospectively reviewed. TPs including local tumor progression (LTP), intrahepatic distant recurrence (IDR), aggressive intrasegmental recurrence (AIR) and extrahepatic distant recurrence (EDR) were reviewed and compared between BCLC stage 0 and A. Univariate and multivariate analysis were performed on clinicopathological variables and different TPs to identify factors affecting long-term overall survival (OS).

RESULTS

In a median follow-up period of 25.6 months (range, 3.1-61.4 months), the rate of LTP, IDR, AIR and EDR was 6.2% (21/340), 29.1% (98/340), 3.2% (11/340) and 7.9% (27/340). The four types of TP occurrence rates in BCLC stage 0 were comparable to those in BCLC stage A (p = 0.492, 0.971, 0.681 and 0.219). Univariate analysis showed that age (p < 0.001, hazard ratio [HR] = 2.783), comorbidities (p = 0.042, HR = 1.864), IDR, AIR and EDR (p = 0.027, HR = 1.719; p = 0.001, HR = 3.628; p = 0.009, HR = 2.638) were independently associated with OS. Multivariate analysis showed older age (p < 0.001, HR = 2.478), the occurrence of AIR (p < 0.001, HR = 2.648) and the occurrence of EDR (p = 0.002, HR = 2.222), were associated with poor OS.

CONCLUSIONS

The occurrence rate of IDR is the highest of all TPs following MWA of a single HCC of <5cm. Old age, AIR and EDR had an adverse effect on long-term OS.

Learning curve for radiofrequency ablation of benign thyroid nodules

Objective: To evaluate the effect of operator experience on the treatment outcomes of radiofrequency ablation (RFA) for benign thyroid nodules (BTN). Methods: Data from the 90 first RFA procedures of a single operator in treating benign thyroid nodules were prospectively collected and retrospectively analyzed. Patients were divided into 3 groups according to their chronological treatment rank: patients 1-30 (G1), 31-60 (G2) and 61-90 (G3). Clinical symptoms, volume reduction ratio (VRR), technique efficacy (TE) defined as a VRR > 50% and ablation ratio (AR) were compared between the three groups at 6 months follow-up. All complications and side effects were recorded. Results: No significant difference was observed in improvement of clinical symptoms after the RFA procedure between the three groups, with higher satisfaction however for pressure symptoms than for esthetic complaints (complete resolution 87.5% and 52.6%, respectively). In groups 1, 2 and 3, TE was 60%, 93.3%, 76.7%, VRR 54%, 65%, 60% and AR 13.1%, 34%, 34.6%, respectively. Thus, all ultrasound efficacy parameters (TE, VRR, AR) improved significantly between G1 and G2, with no difference between G2 and G3. Solely did AR improve in nodules ≤ 30 mL between G2 and G3 to reach a median value of 94.4% in G3 versus 57.1% in G2 and 13.7% in G1. Maximum values of TE and VRR (95.6% and 68%, respectively) were seen in nodules ≤ 30 mL in G2 at 6 months follow-up, with no improvement in G3 (84.2% and 63%, respectively). Both baseline volume and energy per volume were independently associated with VRR and AR. Three minor complications were recorded which all recovered totally after conservative treatment. Conclusion: There was a measurable learning curve in RFA for benign thyroid nodules regarding efficacy until 90 patients. VRR and AR can be used as proficiency markers. Only three transient complications occurred confirming the safety of the procedure.

Volume reduction for ≥2 cm benign breast lesions after ultrasound-guided microwave ablation with a minimum 12-month follow-up

OBJECTIVE

To prospectively evaluate the efficacy of microwave ablation (MWA) for benign breast lesions (BBLs) ≥2 cm and explore the possible factors associated with the volume reduction rate (VRR) of ablated lesions.

MATERIALS AND METHODS

From November 2013 to December 2017, a total of 80 patients with 104 biopsy-proved BBLs larger than 2 cm in size underwent MWA. After the procedure, patients were followed up via physical and imaging examination consisting of contrast-enhanced ultrasound (CEUS) and magnetic resonance imaging (MRI). Possible factors associated with 12-month VRR were assessed, including basic patient characteristics, index lesions and parameters of ablation technique.

RESULTS

The mean tumor size was 2.6 ± 0.6 cm (ranging 2.0-6.3 cm). Of the 104 lesions, 70 were fibroadenomas, 27 adenosis and 7 fibrocystic changes. Post-procedure CEUS or contrast-enhanced MRI showed that all lesions were completely ablated. No immediate or delayed complications were observed. All patients were followed up for more than 12 months (median follow-up 12.5 months). After MWA, the ablated lesion volume decreased significantly by 12 months (p < 0.001), with a mean volume reduction of 80.2 ± 13.1%. Multiple linear regression analysis showed that location adjacent to areola (β = 7.5, 95%CI: 1.0-13.9, p = 0.025) and location adjacent to skin (β = -7.4, 95%CI: -12.7 to -13.9, p = 0.007) were independent factors respectively associated with the increased and decreased 12-month VRR.

CONCLUSION

For BBLs larger than 2 cm, US-guided MWA is a favorable treatment modality, with BBLs adjacent to the areola being associated with more significant 12-month VRR after MWA.

Incremental predictive value of left atrial strain and left atrial appendage function in rhythm outcome of non-valvular atrial fibrillation patients after catheter ablation

Objective

The purpose of this study was to develop a non-invasive and convenient nomogram based on speckle tracking echocardiography, left atrial appendage function and clinical factors to predict the risk of atrial fibrillation (AF) recurrence after catheter ablation.

Methods

A total of 124 prospectively consecutive patients with AF treated with catheter ablation in our hospital was retrospectively analysis. Baseline echocardiographic parameters were measured by using transthoracic and transesophageal echocardiography before ablation. Multivariate analysis was performed for selecting predictors for a nomogram and internal validation and calibration were evaluated by the bootstep method.

Results

During the follow-up of 12±3 months, 41 patients (33.1%) occurred AF recurrence after catheter ablation, while 83 patients (66.9%) had maintained sinus rhythm. Four predictors (AF type, left atrial appendage emptying flow velocity, left Atrial maximal volumes index and global longitudinal strain) with the P<0.5 was selected into the nomogram according to multivariate findings. Internal validation by bootstrapping with 1000 resamples was determined C-index of the nomogram for prediction AF recurrence was 0.901, which showed optimal discrimination and calibration of the established nomogram.

Conclusions

Nomogram based on echocardiography and clinical characteristics had good predictive performance for the possibility of AF recurrence, which providing practical guidance for individualised management of patients with AF after catheter ablation.

Nomograms to predict survival outcomes after microwave ablation in elderly patients (>65 years old) with early-stage hepatocellular carcinoma

Objectives: To develop and validate the nomograms to predict survival outcomes after microwave ablation (MWA) in elderly patients(>65 years old) with early-stage hepatocellular carcinoma (EHCC).Methods: This retrospective study was approved by the institutional review board. A total of 265 EHCC patients (76 females, 189 males; average age 71.4 years ± 5.4 [standard deviation]) with 345 nodules subsequently underwent MWA from April 2006 to October 2019. Baseline characteristics were collected to identify the risk factors for the determination of survival outcomes after MWA. The nomograms were based on prognostic factors for overall survival (OS) and recurrence-free survival (RFS) from the multivariate Cox proportional hazards model and validated in external cohorts from another two institutions (n = 130). The nomograms were assessed for their predictive accuracy using Harrell's concordance index (C-index).Results: After a median follow-up time of 28.6 months, 29.8% (79/265) of the patients died, and 54.3% (144/265) of the patients experienced recurrence in the training set. The OS nomogram was developed based on the hepatitis B virus (HBV) presence, α-fetoprotein (AFP), and albumin, with a C-index of 0.757 (95% confidence interval [CI]: 0.645, 0.789).The scores of the nomogram ranged from 0 to 24. The RFS nomogram was developed based on tumor number, abutting major vessels and platelets, with a C-index of 0.733 (CI: 0.672, 0.774). The likelihood of 3- and 5-year OS and RFS were consistent between clinical observations and nomogram predictions in external cohorts.Conclusions: The nomogram models can be useful in determining the risk of OS and RFS in elderly patients with EHCC after MWA, which can guide individual patient management.Key pointsMWA is an effective and feasible treatment for elderly patients with EHCC and can improve survival outcomes.A calibrated and objective nomogram model for the prediction of survival outcomes in elderly patients (>65 years old) may guide patient selection and MWA treatment.Older age was not deemed to be a risk factor for survival outcomes when the elderly patients with EHCC underwent MWA.

Percutaneous image-guided thermal ablation of bone metastases: a retrospective propensity study comparing the safety profile of radio-frequency ablation and cryo-ablation

OBJECTIVES

To retrospectively compare the safety profile of percutaneous image-guided radiofrequency ablation (RFA) and cryoablation (CA) of bone metastases (BM) with and without a propensity score analysis.

METHODS

Between January 2008 and April 2018, 274 consecutive patients (mean age 61.6 ± 12.1 years) with BM were treated at our Institution with RFA (53 patients; 66 BM) or CA (221 patients; 301 BM) and included in this study. Complications were assessed according to the type of ablation modality before and after applying a 1:1 propensity score method taking into account patient's demographics, BM features, procedural details and follow-up findings.

RESULTS

In the whole 9 BM (2.5%) reported major complications without significant difference between RFA (1/66; 1.5%) and CA (8/301; 2.7%; p = 1); 40 BM (10.9%) showed minor complications, which were more common with RFA (22/66; 33.3%) than with CA (18/301; 6.0%, p<.001) mainly due to post-procedural pain occurring more frequently with RFA than CA (20/66; 30.3% vs. 7/301; 2.3%, p<.001). Following 1:1 matching, similar results were obtained, since there were similar rates of major complications with RFA and CA (1/66 [1.5%] and 0/66 [0.0%], respectively; p = 1); and higher rates of minor complications with RFA compared to CA [33.3% (22/66) vs. 2/66 (3%); p<.001] due to preponderant postprocedural pain (90.9% [20/22] minor complications with RFA).

CONCLUSIONS

Similar low rates of major complications are expected with RFA and CA of BM. In the post-operative period, RFA appears more painful than CA, thus warranting for adoption of dedicated analgesic protocols for patients undergoing RFA.