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

PURPOSE: The purpose of this study was to determine the safety and accuracy of aortic and periaortic computed tomography (CT)-guided percutaneous core needle biopsy performed at a single center over 12 years. MATERIALS AND METHODS: A retrospective review was conducted of cases performed between February 2010 and August 2022 in which the biopsied region was in direct contact with the aorta or great vessels including the pericardium and common iliac arteries. Clinical notes were reviewed for any early or delayed complications following the procedure, which if present were graded using the National Institute of Health's Common Terminology Criteria for Adverse Events, version 5.0. Pathology results were compared to subsequent outside biopsy results or follow-up surgical pathology, if available, as well as subsequent clinical decision making and/or clinical course, to determine concordance. Sensitivity, specificity, predictive value, and accuracy (indicative of diagnostic yield) were calculated. RESULTS: 32 core needle biopsies were reviewed from 30 patients (average lesion longest diameter 3.1 cm, range 0.5-10.9 cm; average needle proximity to the vessel endothelium or deep side of the pericardium 1.0 cm, range 0.3-1.8 cm). Complications occurred in 46.9% of cases (15/32), 93.3% (14/15) of which were minor and included small amounts of bleeding or pain. One patient developed a small nonemergent pneumothorax. Of biopsies obtained, 96.9% provided adequate tissue for diagnosis (31/32). When evaluating concordance between pathological and final diagnosis, sensitivity was 94.7% and specificity was 83.3%; positive and negative predictive value were 90.0% and 90.9%, respectively. Accuracy (diagnostic yield) of biopsy was 90.3%. CONCLUSION: CT-guided percutaneous aortic and periaortic core needle biopsies are safe and efficacious procedures with high diagnostic yield.

Musculoskeletal Oncologic Interventions: Proceedings from the Society of Interventional Radiology and Society of Interventional Oncology Research Consensus Panel.

Musculoskeletal interventions are increasingly used with palliative and curative intent in the multidisciplinary treatment of oncology patients with bone and soft-tissue tumors. There is an unmet need for high-quality evidence to guide broader application and adoption of minimally invasive interventional technologies to treat these patients. Therefore, the Society of Interventional Radiology Foundation and the Society of Interventional Oncology collaborated to convene a research consensus panel to prioritize a research agenda addressing the gaps in the current evidence. This article summarizes the panel's proceedings and recommendations for future basic science and clinical investigation to chart the course for interventional oncology within the musculoskeletal system. Key questions that emerged addressed the effectiveness of ablation within specific patient populations, the effect of combination of ablation with radiotherapy and/or immunotherapy, and the potential of standardization of techniques, including modeling and monitoring, to improve the consistency and predictability of treatment outcomes.

Initial testing of pegfilgrastim (Neulasta Onpro) on-body injector in multiple radiological imaging environments.

PURPOSE: An increasing number of implantable or external devices can impact whether patients can receive radiological imaging examinations. This study examines and tests the Neulasta (pegfilgrastim) Onpro on-body injector in multiple imaging environments. METHODS: The injector was analyzed for four imaging modalities with testing protocols and strategies developed for each modality. In x-ray and computed tomography (CT), scans with much higher exposure than clinical protocols were performed with the device attached to an anthropomorphic phantom. The device was monitored until the completion of drug delivery. For magnetic resonance imaging (MRI), the device was assessed using a hand-held magnet and underwent the magnetically induced displacement testing in a 1.5T clinical MRI scanner room. For ultrasound, magnetic field changes were measured around an ultrasound scanner system with three transducers. RESULTS: For x-ray and CT no sign of device error was identified during or after the high radiation exposure scans. Drug delivery was completed at expected timing with expected volume. For MRI the device showed significant attractive force towards the hand-held magnet and a 50-degree deflection angle at 50 cm from the opening of the scanner bore. No further assessment from the gradient or radiofrequency field was deemed necessary. For ultrasound the maximum magnetic field change from baseline was measured to be +11.7 µT in comparison to +74.2 µT at 4 inches from a working microwave. CONCLUSIONS: No device performance issue was identified under the extreme test conditions in x-ray or CT. The device was found to be MR Unsafe. Magnetic field changes around an ultrasound system met the limitation set by manufacture. Patient ultrasound scanning is considered safe as long as the transducers do not inadvertently loosen the device.

Image-Guided Thermal Ablative Therapies in the Treatment of Sarcoma.

OPINION STATEMENT: Percutaneous thermal ablation, including microwave ablation (MWA), radiofrequency ablation (RFA), and cryoablation, is a well-established focal treatment option for primary and metastatic malignancies. While published literature specific to ablation of sarcomas is relatively lacking compared with non-sarcomatous malignancies, what is available is promising. In situations where a focal treatment option is desired, strong consideration should be given to percutaneous thermal ablation, in addition to surgery and radiation therapy. A significant advantage of percutaneous thermal ablation over surgery and radiation includes the repeatability of ablation, as there is no absolute limit on the number of times an ablation can be performed. Compared with surgery, ablation offers the potential of decreased recovery time, a less invasive procedure, and is often performed in patients deemed not medically fit for surgery.

Comprehensive assessment of renal tumour complexity in a large percutaneous cryoablation cohort.

OBJECTIVE: To evaluate the association between renal tumour complexity and outcomes in a large cohort of patients undergoing percutaneous cryoablation (PCA). PATIENTS AND METHODS: Patients with renal tumours treated with PCA were identified using our prospectively maintained ablation registry (2003-2015). Salvage procedures and inherited tumour syndromes were excluded. The associations between R.E.N.A.L. nephrometry score (NS) and risk of complications, renal function impairment, local failure and cancer-specific mortality (CSM) were evaluated using univariate and multivariable logistic, linear and Cox regression models. RESULTS: The cohort included 618 tumours treated during 580 procedures in 565 patients. The median (interquartile range [IQR]) follow-up was 34 (14.66) months. Complications (any grade) during a procedure (n[total] = 87, 15%) were more frequent with higher NS (NS 4-6: 10%; NS 7-9: 14%; NS 10-12: 36%; P < 0.001). Higher NS was independently associated with risk of complications (odds ratio [OR; per 1 point] = 1.3; 95% confidence interval [CI] 1.2-1.5; P < 0.001). Of all the NS components, tumour size was the most strongly associated with complication risk (OR 3.4; 95% CI 2.2-5.2; P < 0.001). The median (IQR) decline in glomerular filtration rate (GFR) from baseline was 9% (0, 22) at last follow-up. Each additional point in NS was associated with a 1.3% (95% CI 0.4-2.1; P = 0.005) greater GFR decline from baseline. NS was not significantly associated with local failure (n [total] = 14, 2%; NS 4-6: 2%; NS 7-9: 3%; NS 10-12: 5%; P = 0.32) or CSM (n [total] = 8, 2%; NS 4-6: 2%; NS 7-9: 3%; NS 10-12: 2%; P = 0.88). CONCLUSION: In high-complexity tumours PCA was associated with a tumour size-driven increased risk of post-procedural complications. Higher NS was associated with a small, clinically minor additional decline in renal function. Risks for local failure and CSM were low, regardless of tumour complexity.

Increasing Role of Image-Guided Ablation in the Treatment of Musculoskeletal Tumors.

In the last decade, percutaneous treatment of musculoskeletal (MSK) tumors has become more established in routine clinical care while also undergoing a number of advancements. Ablative techniques to palliate painful skeletal metastases have gained wide acceptance, while goals for ablation have evolved to include local control of oligometastases and desmoid tumors. Bone consolidation or augmentation is now frequently used in conjunction with or instead of ablation of skeletal tumors to stabilize pathologic fractures or prevent further morbidity that could result from fractures caused by tumor progression. These procedures have traditionally been performed with cement injection, although additional percutaneous consolidation or stabilization devices have been developed. Techniques to monitor the ablation zone and adjacent structures intraprocedurally are now applied to increase the number of tumors amenable to treatment. These include methods to depict, displace, or monitor critical structures adjacent to targeted MSK tumors. Finally, the role of ablation in the comprehensive care of patients with MSK tumors continues to change with the evolving triage of patients between radiation therapy, surgical resection and stabilization, and percutaneous ablative and consolidative management.

Motor evoked potential monitoring during cryoablation of musculoskeletal tumors.

PURPOSE: To describe the use of intraprocedural motor evoked potential (MEP) monitoring to minimize risk of neural injury during percutaneous cryoablation of perineural musculoskeletal tumors. MATERIALS AND METHODS: A single-institution retrospective review of cryoablation procedures performed to treat perineural musculoskeletal tumors with the use of MEP monitoring between May 2011 and March 2013 yielded 59 procedures to treat 64 tumors in 52 patients (26 male). Median age was 61 years (range, 4-82 y). Tumors were located in the spine (n = 27), sacrum (n = 3), retroperitoneum (n = 4), pelvis (n = 22), and extremities (n = 8), and 21 different tumor histologies were represented. Median tumor size was 4.0 cm (range, 0.8-15.0 cm). Total intravenous general anesthesia, computed tomographic guidance, and transcranial MEP monitoring were employed. Patient demographics, tumor characteristics, MEP findings, and clinical outcomes were assessed. RESULTS: Nineteen of 59 procedures (32%) resulted in decreases in intraprocedural MEPs, including 15 (25%) with transient decreases and four (7%) with persistent decreases. Two of the four patients with persistent MEP decreases (50%) had motor deficits following ablation. No functional motor deficit developed in a patient with transient MEP decreases or no MEP change. The risk of major motor injury with persistent MEP changes was significantly increased versus transient or no MEP change (P = .0045; relative risk, 69.8; 95% confidence interval, 5.9 to > 100). MEP decreases were 100% sensitive and 70% specific for the detection of motor deficits. CONCLUSIONS: Persistent MEP decreases correlate with postprocedural sustained motor deficits. Intraprocedural MEP monitoring helps predict neural injury and may improve patient safety during cryoablation of perineural musculoskeletal tumors.

Cryoablation of sternal metastases for pain palliation and local tumor control.

PURPOSE: To determine safety and effectiveness of cryoablation of sternal metastases for pain palliation and local tumor control. MATERIALS AND METHODS: A tumor ablation database was retrospectively reviewed for sternal cryoablation procedures performed between January 2005 and June 2013, which yielded 15 procedures to treat 12 sternal metastases in 12 patients (five men). Median patient age was 57 years (range, 38-80 y). Metastases arose from five primary sites (breast, lung, kidney, ampulla, and thyroid), and median tumor size was 3.8 cm (range, 2.2-7.5 cm). Seven patients (58%) underwent cryoablation for pain palliation, and five (42%) underwent cryoablation for local tumor control of oligometastatic disease. Clinical outcomes (including complications, local tumor control, and pain response) were evaluated retrospectively. RESULTS: Mean pain scores decreased from 7.0 ± 1.9 (median, 7; range, 4-10) at baseline to 1.8 ± 1.2 (median, 1.5; range, 0-4) following cryoablation (P = .00049). Two patients had durable pain palliation, and four had greater than 1 month of pain relief, with a median duration of 5.7 months (range, 1.5-14.7 mo). Two patients in whom recurrent pain developed underwent repeat cryoablation, with durable pain relief. Allowing for a single repeat treatment, local tumor control was achieved in four of five patients (80%) treated for this indication, with median follow-up of 8.4 months (range, 2.6-13.6 mo). In one patient (8%), an infectious complication developed that was successfully treated with antibiotics on an outpatient basis. CONCLUSIONS: Cryoablation is a safe and potentially effective treatment for patients with painful sternal metastases and can achieve local tumor control in select patients.

Ablation of musculoskeletal metastases: pain palliation, fracture risk reduction, and oligometastatic disease.

Thermal ablation is an effective, minimally invasive alternative to conventional therapies in the palliation of painful musculoskeletal metastases and an emerging approach to obtain local tumor control in the setting of limited metastatic disease. Various thermal ablation technologies have been applied to bone and soft tissue tumors and may be used in combination with percutaneous cement instillation for skeletal lesions with or at risk for pathologic fracture. This article reviews current practices of percutaneous ablation of musculoskeletal metastases with an emphasis on radiofrequency ablation and cryoablation of painful skeletal metastases.

Cryoablation of recurrent sacrococcygeal tumors.

PURPOSE: To review the safety and efficacy of cryoablation of recurrent sacrococcygeal tumors. MATERIALS AND METHODS: The radiology departmental ablation database was retrospectively searched for cases of cryoablation performed to treat recurrences of sacrococcygeal tumors between January 1, 2010, and August 1, 2011. Patient demographics, procedure technical parameters, and patient outcomes were reviewed. RESULTS: Five cases of recurrent chordoma and one recurrent myxopapillary ependymoma were treated with cryoablation in six patients whose ages ranged from 31 to 80 years. The tumors measured 14-39 mm in maximal dimension. Cryoablation was performed with the use of computed tomography guidance (n = 5) or a combination of ultrasound and magnetic resonance imaging guidance (n = 1). Sterile fluid was instilled to displace adjacent bowel and/or vagina in four cases, and electromyography monitoring was performed in two cases with adjacent nerve roots. Two patients with recurrent chordoma were treated for palliation of pain, with complete pain relief in one patient (pain recurred after 6 wk) and immediate reduction in pain from a score of six to a score of two on a 10-point scale in the other (pain recurred after 7 mo). Four tumors were treated for local control, with no evidence of recurrence on follow-up imaging at 3, 6, 12, and 15 months. No serious complication occurred. CONCLUSIONS: Limited results suggest cryoablation to be a safe and relatively effective means of treating recurrent sacrococcygeal neoplasms for local control or palliation of pain in this small series with short-term follow-up.

Renal oncocytoma growth rates before intervention.

OBJECTIVE: To describe the growth rates of oncocytomas before treatment with surgical resection or percutaneous ablation. PATIENTS AND METHODS: This single-institution retrospective study included 33 consecutive, pathologically proven renal oncocytomas with serial contrast-enhanced computed tomography scans spanning at least 1 year before intervention, from 2000 to 2009. Tumours were measured by two radiologists, and growth rates and interobserver variability were calculated. The mean (range) pre-procedural imaging surveillance period was 36 (12-124) months (median 33 months). RESULTS: The mean (SD) oncocytoma size was 17 (11) mm (range 4-47 mm, median 15 mm) in maximum transverse diameter on initial imaging and grew to a mean (SD) of 26 (5) mm (range 10-83 mm, median 23 mm) by the time of treatment. Overall, the mean (SD) and median growth rates were 2.9 (2.6) mm/year and 2.7 mm/year, respectively (range -1.2-10.9 mm/year). After weighting by the se of each tumour's growth rate, the mean (SD) change was 2.1 (1.2) mm/year. The mean (range) interobserver variability for each tumour measurement was 1 (0-7) mm with an intraclass correlation coefficient of 0.99. CONCLUSIONS: Renal oncocytomas grow at a rate similar to reported growth rates of renal cell carcinoma. As the observation of growth does not distinguish between benign and malignant renal tumours, growth of small renal masses under active surveillance should be carefully considered before a switch is made to intervention.