Precision pain management in interventional radiology

Pain is a common manifestation of several benign and malignant conditions. Inadequate response to conservative therapies is often succeeded by incremental use of analgesics and opioids; however, such an approach is often ineffective, not well tolerated by patients, and carries the risk of addiction leading to the opioid crisis. Implementing minimally invasive percutaneous procedures, performed by interventional radiologists has proven to be successful in providing safe, effective, and patient-specific therapies across a wide range of painful conditions. In the present narrative review, we will review the repertoire of minimally invasive imaging guided interventions, which have been successfully used to treat common painful benign and malignant conditions. We briefly describe each technique, common indications, and expected results.

455 The Changing Trends of Image Guided Biopsy of Small Renal Masses Before Intervention- an Analysis of European Multinational Prospective EuRECA Registry

Aim

To evaluate the use of pre-cryoablation biopsy for small renal masses (SRMs) and the effects of increasing up take on histological results of treated SMRs.

Method

From 2015 to 2019, patients with sporadic T1N0M0 SRMs undergoing percutaneous, laparoscopic or open cryoablation from 14 European institutions within the European Registry For Renal Cryoablation (EuRECA) were included for the retrospective analysis. Univariate and multivariate logistic models were used to evaluate the trends, histological results and the factors influencing use of pre-cryoablation biopsy.

Results

871 patients (Median [IQR] age, 69[14], 298 women) undergoing cryoablation were evaluated. The use of pre-cryoablation biopsy has significantly increased from 42% (65/156) in 2015 to 72% (88/122) in 2019 (p<0.001). Patients treated for a benign histology are significantly more likely to have presented later in the trend, where pre-cryoablation biopsy is more prevalent (OR: 0.64, 95% CI 0.51–0.81, p<0.001). Patients treated for undiagnosed histology are also significantly less likely to have presented in 2018 compared to 2016 (OR 0.31, 95% CI 0.10–0.97, p=0.044). Patients aged 70+ are less likely to be biopsies pre-cryoablation (p<0.05). R.E.N.A.L. nephrometry score of 10+ and a Charlson Comorbidity Index >1 are factors associated with lower likelihood to not have received a pre-cryoablation biopsy (p<0.05).

Conclusion

An increased use of pre-cryoablation biopsy was observed and cryoablation patients treated with a benign histology is more likely to have presented in periods where pre-cryoablation biopsy is not as prevalent. Comparative studies are needed to draw definitive conclusions on the effect of pre-cryoablation biopsy on SRM treatments.

Interventional magnetic-resonance-guided cryotherapy combined with microsurgery for recurrent glioblastoma: An innovative treatment?

BACKGROUND

Glioblastoma invariably recurs after primary Stupp tumor therapy and portends a poor prognosis. Cryoablation is a well-established treatment strategy for extra-cranial tumors. The safety and efficacy of interventional MR-guided cryoablation (iMRgC) has not been explored in recurrent glioblastoma.

METHODS

A retrospective analysis of data collected over a period of 24 months was performed. The inclusion criteria were: (I) recurrent glioblastoma despite Stupp protocol; (II) MRI followed by histological confirmation of recurrent glioblastoma; (III) location allowing iMRgC followed by microsurgical resection; and (IV) patient's consent. The primary objective was to assess feasibility in terms of complications. The secondary objective was to analyze progression-free survival (PFS), post-iMRgC survival and overall survival (OS).

RESULTS

The study included 6 patients, with a mean age of 67±7.6 years [range, 54-70 years]. No major complications were observed. Median PFS was 7.5 months [IQR 3.75-9.75] and 6-month PFS was 50%. Median post-iMRgC survival was 9 months [IQR 7.5-15.25] and 6-month post-iMRgC survival was 80%. Median OS was 22.5 months [IQR 21.75-30].

CONCLUSION

iMRgC for recurrent glioblastoma demonstrated a good safety profile, with no major complications. Our data suggest improved PFS and OS.

TRIAL REGISTRATION NUMBER

No. IRB00011687 retrospectively registred on July 7th 2021.

Pain relief and local tumour control following percutaneous image-guided cryoablation for spine metastasis: a 12-year single-centre experience

AIM

To assess pain relief and local tumour control retrospectively in spinal metastases undergoing cryoablation.

MATERIALS AND METHODS

Between May 2008 and September 2020, 46 metastases in 41 consecutive patients (mean age 59.7±4.4 [SD] years; range 27-84) were treated with cryoablation in 42 interventional sessions. Patient demographics, procedural data, complications, pain, and local tumour control were analysed retrospectively.

RESULTS

Thirty-one patients (36 spine metastases; 32 sessions) were treated for pain relief and 10 (10 metastases; 10 sessions) for local tumour control. Clinical success was reached in 30/32 (93.8%) interventional palliative sessions. Mean pre-procedural numerical pain rate scale was 6.2±1.7 (SD), and dropped significantly to 3.5±1.8 (SD), 1.9±1.7 (SD), and 1.9±1.8 (SD) at 24-h, 1-month and at the last available follow-up (median 16.5±23.2 [SD] months), respectively. For patients requiring local tumour control, primary clinical success was reached in 6/10 (60%) spinal metastases at median 25-months follow-up. The overall complication rate was 8%, with no secondary fractures or iatrogenic thermal-mediated nerve injuries reported.

CONCLUSION

Percutaneous image-guided cryoablation of spinal metastases is safe and effective in achieving pain relief and local tumour control.

Robot-Assisted Bone Cement Injection

In this article, assistance to bone cement injection is studied, with a focus on vertebroplasty, a procedure dedicated to the treatment of vertebral compression fractures. A robotic system that can remotely be operated at pressures up to 140 bar is presented. It improves cement polymerization control, combining a cold passive exchanger that slows down the cement curing in the syringe and an active exchanger that controls the injected cement temperature. The cement remote injection uses a rate control teleoperation strategy with force feedback to help monitoring the cement state. In addition to laboratory assessments, cadaver experiments were performed to illustrate the satisfactory operation of the whole system.

The Cryo-immunologic effect: A therapeutic advance in the treatment of glioblastomas?

The immunotherapy of cerebral glioblastoma has become a hot topic. Immune checkpoint blockade antibodies have progressively acquired a role in the management of malignant tumors. A multimodal approach using surgery, radiotherapy, chemotherapy in combination with immunotherapy represent a potent weapon against glioblastomas. In parallel, clinical applications of cryotherapy-freezing tumors based on repetition of rapid freeze-slow thaw cycle-for various cancers such as skin, lung, breast, esophagus, hepatic, kidney, prostate and bone tumors were developed. The future immunomodulatory approaches might be combined with brain tumors cryoablation to increase the cryoimmune response. The objective of this study was to analyze from the literature the relationship between cerebral cryosurgery and immunomodulation using PRISMA method. The animals' studies demonstrate the dendritic cells maturation and activation with the enhancement of antigen-presenting function after cryotherapy suggesting the potential usefulness of the association of cryotherapy and immunomodulator in the management of gliomas.

Percutaneous image-guided double oblique anterior approach to the acetabulum for cementoplasty

AIM

To report the technique of percutaneous double oblique anterior access to the acetabulum and evaluate its feasibility and safety.

MATERIALS AND METHODS

Pelvic computed tomography (CT) examinations of 60 patients (30 men and 30 women; mean age 62.6±13.2 years) were retrieved randomly from the picture archiving and communication system (PACS). A virtual intraosseous trajectory was defined on both sides on the axial CT images with the entry point marked 1 cm above the anterosuperior iliac spine and the endpoint defined just above the level of the ischial spine at the midpoint of the posterior acetabulum. Patient age, sagittal oblique angulation, axial oblique angulation, length of intraosseous trajectory, distance from the hip joint, thickness of the iliac bone cortex, and intervening structure(s) between the skin and the bone entry points were recorded.

RESULTS

The mean sagittal and axial oblique angulations were 34.2±4.5° and 31.5±6.7°, respectively, and mean length of the intraosseous trajectory was 11.8±0.9 cm. The axial oblique angle and length of the intraosseous trajectory were significantly lower in the female than the male population (p<0.05). None of the virtual trajectories traversed the hip joint. In 112/120 trajectories (93.3%), there were no cortical breaches in the iliac bones. In eight trajectories in four patients, the virtual trajectory crossed either the medial iliac cortex (4/120; 3.3%) or the medial iliac cortex and the iliacus muscle (4/120; 3.3%).

CONCLUSION

The anterosuperior iliac and ischial spines can be used safely and reliably as landmarks to perform the double oblique anterior approach.

[Percutaneous MR-guided prostate cancer cryoablation: Predictive factors and oncologic outcomes]

OBJECTIVE

To determine the pejorative predictive factors on oncologic outcomes of percutaneous MR-guided whole gland prostate cancer cryoablation (CA).

METHODS

Medical records of patients treated from 2009 to 2012, to assess medium-term oncologic outcomes, were reviewed. Prostate biopsies were performed in local recurrence suspicion (biochemical failure, MR follow-up failure).

RESULTS

Among 18 patients, mean age of 72.6 (61-78), 2 (11 %) and 7 (38.9 %) biological and reported biopsy-proven local recurrence respectively with our initial technic of CA. Mean follow-up and recurrence were 56.3 (±21.7) and 20.7 (±13.9) months respectively. A previous treatment of prostate cancer (P=0.5), pre-treatment PSA (P=0.2), pre-treatment Gleason/ISUP score (P=0.4), nadir PSA post-CA (P=0.22) were not associated with recurrence. Bilateral positive cores appears as a pejorative predictive factor (P=0.04). However mean pre-treatment positive cores percentage, 25 (±16.5) in responding patients versus 40.7 (±25.2) in case of recurrence, and maximum percentage of cancer extent in each positive core, 10.6 (±9.3) in responding patients versus 18.7 (±16.5) in case of recurrence, seemed associated with local recurrence after prostate CA but our analysis wasn't able to find a difference (P=0.09 and P=0.3 respectively) due to a lack of power.

CONCLUSION

Bilateral positive cores appears as a pejorative predictive factor. In our experience, important tumor volume seem to be a pejorative predictive factor for oncologic outcomes after PCA whereas treatment, PSA, Gleason/ISUP score, nadir PSA are not.

LEVEL OF EVIDENCE

4.

Transforaminal Insertion of a Thermocouple on the Posterior Vertebral Wall Combined with Hydrodissection during Lumbar Spinal Radiofrequency Ablation

The purpose of the present article is to describe the technique of transforaminal insertion of an ultrathin thermosensor in the anterior epidural space in 13 patients treated by radiofrequency ablation. The mean time taken to position the thermosensor was 10.6 minutes (range, 5-38 minutes). Technical success was 93% (correct positioning in 13/14 levels). Additional hydrodissection was performed through the same access in 11 cases. No postoperative neural deficit was elicited in any of the cases.

Percutaneous extra-spinal cementoplasty in patients with cancer: A systematic review of procedural details and clinical outcomes

PURPOSE

To perform a systematic review of technical details and clinical outcomes of percutaneous extra-spinal cementoplasty in patients with malignant lesions.

MATERIALS AND METHODS

PUBMED, MEDLINE, MEDLINE in-process, EMBASE and the Cochrane databases were searched between January 1990 and February 2019 using the keywords «percutaneous cementoplasty», «percutaneous osteoplasty» and «extra-spinal cementoplasty». Inclusion criteria were: retrospective/prospective cohort with more than 4 patients, published in English language, reporting the use of percutaneous injection of cement inside an extra-spinal bone malignant tumour using a dedicated bone trocar, as a stand-alone procedure or in combination with another percutaneous intervention, in order to provide pain palliation and/or bone consolidation.

RESULTS

Thirty articles involving 652 patients with a total of 761 lesions were reviewed. Mean size of lesion was 45mm (range of mean size among publications: 29-73mm); 489 lesions were located in the pelvis, 262 in the long bones of the limbs and 10 in other locations. Cementoplasty was reported as a stand-alone procedure for 60.1% of lesions, and combined with thermal ablation for 26.2% of lesions, implant devices for 12.3% of lesions, and balloon kyphoplasty for 1.4% of lesions. The mean volume of injected cement was 8.8mL (range of mean volume among publications: 2.7-32.2mL). The preoperative visual analogic scores ranged between 3.2 and 9.5. Postoperative scores at last available follow-up ranged from 0.4 to 5.6. Thirteen papers reported a reduction of the visual analogic scores of 5 points or more. Nerve injury was the most frequent symptomatic leakage (0.6%).

CONCLUSION

Percutaneous extra-spinal cementopasty is predominantly performed as a stand-alone procedure and for lesions in the bony pelvis. It appears to be an effective tool to manage pain associated with malignant bone tumours. There is however a lack of standardization of the technique among the different publications.

Preclinical evaluation of the atraumatic nature of a spring loaded blunt tip coaxial needle in a swine model

PURPOSE

To test in vivo in an animal model the inherent atraumatic characteristics of the spring loaded blunt tip of a coaxial needle (Gangi-SoftGuard®, Apriomed, Sweden) against a conventional sharp stylet coaxial needle.

MATERIAL AND METHODS

The study was conducted on a 40kg male swine that was its own control for a vascular trauma model. The procedure consisted of voluntary attempts to transfix and traverse the artery/aorta under continuous real-time angiogram. Test and control needles were positioned in the region of the intercostal, superior mesenteric and femoral/deep femoral arteries, and in the aorta. Computed tomography (CT) angiogram was performed post trauma to check for bleeding in the form of extravasation of contrast material. One attempt was performed per site and needle, except for the intercostal artery where a second attempt was done with the test needle, resulting in a total of 4 and 5 tests for the control and test needles, respectively.

RESULTS

With the spring loaded blunt tip, no vascular trauma or bleeding was noted in the intercostal, superior mesenteric and femoral arteries, nor in the aorta. Vascular spasm that recovered with time was noted during the second attempt to transfix the same intercostal artery. There were consistent vascular traumas and bleedings with the control needle in all three tested arteries and the aorta, confirmed on angiogram as well as CT angiogram.

CONCLUSION

The atraumatic feature offered by the spring loaded blunt tip prevented vascular trauma during the 5 attempts made to transfix the artery/aorta in a swine.

Innervation of flexor hallucis longus muscle: an anatomical study for selective neurotomy

BACKGROUND

The aim of the study was to describe the innervation of flexor hallucis longus (FHL) and obtain its surgical coordinates to facilitate selective neurotomy.

MATERIALS AND METHODS

Fifteen embalmed lower limbs of adults were studied. Anatomical dissections to isolate the innervating branches of FHL were performed. Distance between the supplying nerve of FHL, including both its origin and termination, and the medial malleolus were obtained, providing anatomical coordinates beneficial for surgery.

RESULTS

In all cases, FHL was innervated by only one branch, which originated from the tibial nerve. Mean distance between the medial malleolus and the nervous branch origin was 21.39 ± 3.05 cm. Mean distance between the medial malleolus and the nervous branch termination was 12.7 ± 1.59 cm. Length of the nervous branch innervating FHL was proportional to the length of the leg, measuring 8.69 ± 2.45 cm. All nerves were located 15-17.4 cm above the medial malleolus.

CONCLUSIONS

This anatomical study traced valuable surgical coordinates useful for performing selective peripheral neurotomy on the nerve branch innervating the FHL.

[Percutaneous renal ablation: Pre-, per-, post-interventional evaluation modalities and adapted management]

OBJECTIVES

Ablative treatment (AT) rise is foreseen, validation of steps to insure good proceedings is needed. By looking over the process of the patient, this study evaluates the requirements and choices needed in every step of the management.

METHODS

We searched MEDLINE^®, Embase^®, using (MeSH) words and we looked for all the studies. Investigators graded the strength of evidence in terms of methodology, language and relevance.

RESULTS

Explanations of AT proposal rather than partial nephrectomy or surveillance have to be discussed in a consultation shared by urologist and interventional radiologist. Per-procedure choices depend on predictable ballistic difficulties. High volume, proximity of the hilum or of a risky organ are in favor of general anesthesia, cryotherapy and computed tomography/magnetic resonance imaging (CT/MRI). Percutaneous approach should be privileged, as it seems as effective as the laparoscopic approach. Early and delayed complications have to be treated both by urologist and radiologist. Surveillance by CT/MRI insure of the lack of contrast-enhanced in the treated area. Patients and tumors criteria, in case of incomplete treatment or recurrence, are the key of the appropriate treatment: surgery, second session of AT, surveillance.

CONCLUSION

AT treatments require patient's comprehension, excellent coordination of the partnership between urologist and radiologist and relevant choices during intervention.

MRI-Guided Percutaneous Biopsy of Mediastinal Masses Using a Large Bore Magnet: Technical Feasibility

OBJECTIVE

To evaluate the diagnostic accuracy and safety of magnetic resonance imaging (MRI)-guided percutaneous biopsy of mediastinal masses performed using a wide-bore high-field scanner.

MATERIALS AND METHODS

This is a retrospective study of 16 consecutive patients (8 male, 8 female; mean age 74 years) who underwent MRI-guided core needle biopsy of a mediastinal mass between February 2010 and January 2014. Size and location of lesion, approach taken, time for needle placement, overall duration of procedure, and post-procedural complications were evaluated. Technical success rates and correlation with surgical pathology (where available) were assessed.

RESULTS

Target lesions were located in the anterior (n = 13), middle (n = 2), and posterior mediastinum (n = 1), respectively. Mean size was 7.2 cm (range 3.6-11 cm). Average time for needle placement was 9.4 min (range 3-18 min); average duration of entire procedure was 42 min (range 27-62 min). 2-5 core samples were obtained from each lesion (mean 2.6). Technical success rate was 100%, with specimens successfully obtained in all 16 patients. There were no immediate complications. Histopathology revealed malignancy in 12 cases (4 of which were surgically confirmed), benign lesions in 3 cases (1 of which was false negative following surgical resection), and one inconclusive specimen (treated as inaccurate since repeat CT-guided biopsy demonstrated thymic hyperplasia). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy in our study were 92.3, 100, 100, 66.7, and 87.5%, respectively.

CONCLUSION

MRI-guided mediastinal biopsy is a safe procedure with high diagnostic accuracy, which may offer a non-ionizing alternative to CT guidance.

Pullout characteristics of percutaneous pedicle screws with different cement augmentation methods in elderly spines: An in vitro biomechanical study

BACKGROUND

Vertebroplasty prefilling or fenestrated pedicle screw augmentation can be used to enhance pullout resistance in elderly patients. It is not clear which method offers the most reliable fixation strength if axial pullout and a bending moment is applied. The purpose of this study is to validate a new in vitro model aimed to reproduce a cut out mechanism of lumbar pedicle screws, to compare fixation strength in elderly spines with different cement augmentation techniques and to analyze factors that might influence the failure pattern.

MATERIALS AND METHODS

Six human specimens (82-100 years) were instrumented percutaneously at L2, L3 and L4 by non-augmented screws, vertebroplasty augmentation and fenestrated screws. Cement distribution (2 ml PMMA) was analyzed on CT. Vertebral endplates and the rod were oriented at 45° to the horizontal plane. The vertebral body was held by resin in a cylinder, linked to an unconstrained pivot, on which traction (10 N/s) was applied until rupture. Load-displacement curves were compared to simultaneous video recordings.

RESULTS

Median pullout forces were 488.5 N (195-500) for non-augmented screws, 643.5 N (270-1050) for vertebroplasty augmentation and 943.5 N (750-1084) for fenestrated screws. Cement augmentation through fenestrated screws led to significantly higher rupture forces compared to non-augmented screws (P=0.0039). The pullout force after vertebroplasty was variable and linked to cement distribution. A cement bolus around the distal screw tip led to pullout forces similar to non-augmented screws. A proximal cement bolus, as it was observed in fenestrated screws, led to higher pullout resistance. This cement distribution led to vertebral body fractures prior to screw pullout.

CONCLUSION

The experimental setup tended to reproduce a pullout mechanism observed on radiographs, combining axial pullout and a bending moment. Cement augmentation with fenestrated screws increased pullout resistance significantly, whereas the fixation strength with the vertebroplasty prefilling method was linked to the cement distribution.

Characterization of the genes encoding a receptor-like histidine kinase and a cognate response regulator from a biphenyl/polychlorobiphenyl-degrading bacterium, Rhodococcus sp. strain M5

We report the cloning, sequence, and expression of the bpdS and bpdT genes from Rhodococcus sp. strain M5, which are believed to encode the first two-component signal transduction system in the genus Rhodococcus, which potentially regulates biphenyl/polychlorobiphenyl metabolism in M5. BpdT has a typical responses regulator sequence (209 amino acids; 23 kDa), whereas BpdS, the predicted histidine kinase component, is an unusually large transmembrane protein (1,576 amino acids; 170 kDa) that contains ATP-binding and leucine-rich repeat motifs and some conserved residues of protein kinases. Expression of bpdST, like that of the bpdC1C2BADE degradative operon, is inducible by biphenyl.

Location and sequence analysis of a 2-hydroxy-6-oxo-6-phenylhexa-2,4-dienoate hydrolase-encoding gene (bpdF) of the biphenyl/polychlorinated biphenyl degradation pathway in Rhodococcus sp. M5

The 2-hydroxy-6-oxo-6-phenylhexa-2,4-dienoate (HOPD) hydrolase-encoding gene (bpdF) in the biphenyl (BP)/polychlorinated biphenyl (PCB)-degrading bacterium, Rhodococcus sp. M5 (M5), was found to be located within a 4.5-kb HindIII-BamHI genomic DNA that was 5.4 kb downstream from the bpdC1C2BADE gene cluster. The deduced amino acid (aa) sequence of bpdF revealed that the hydrolase contains 297 aa (32679 Da) that was verified by expression in the Escherichia coli T7 RNA polymerase/promoter system. Unlike previously known HOPD hydrolases, the aa sequence of BpdF appears unique. Interestingly, all HOPD hydrolases and related proteins from the phenol and toluene/xylene degradation pathways, were found to have a bias in the codon usage in the catalytic Ser within the conserved VGNS(M/F)GG motif.

Sequence and expression of the bpdC1C2BADE genes involved in the initial steps of biphenyl/chlorobiphenyl degradation by Rhodococcus sp. M5

The nucleotide (nt) sequence of the bpdC1C2BADE genes which encode the first three enzymes in the biphenyl (BP) degradation pathway of Gram+ Rhodococcus sp. M5 (formerly Arthrobacter M5) was determined. Except for the ferredoxin component (BpdB) of the initial BP dioxygenase, the predicted amino acid (aa) sequences of the remaining proteins are found to be more closely related to the counterpart proteins (TodC1C2BADE) present in the toluene-degrader, Pseudomonas putida F1, than those of three BP-degrading pseudomonads. The cloned bpd genes were verified by their expression in the Escherichia coli T7 RNA polymerase/promoter system. In E. coli, BpdA was able to complement TodC1C2B in indigo biosynthesis, although the M5 native or cloned BP dioxygenase does not carry out this reaction.