A multicenter comparative matched-pair analysis of percutaneous tumor ablation and robotic-assisted partial nephrectomy of T1b renal cell carcinoma (AblatT1b study-UroCCR 80).

OBJECTIVE: Renal cell carcinomas represent the sixth- and tenth-most frequently diagnosed cancer in men and women. Recently, percutaneous-guided thermal ablations have proved to be as effective as partial nephrectomy and safer for treating small renal masses (i.e., < 3 cm). This study compared the perioperative and recurrence outcomes of percutaneous thermal ablation (TA) and robotic-assisted partial nephrectomy (RAPN) for the treatment of T1b renal cell carcinomas (4.1-7 cm). METHODS: Retrospective data from 11 centers on the national database, between 2010 and 2020, included 81 patients treated with thermal ablation (TA) and 308 patients treated with RAPN for T1b renal cell carcinoma, collected retrospectively and matched for tumor size, histology results, and the RENAL score. TA included cryoablation and microwave ablation. Endpoints compared the rate between the two groups: local recurrence, metastases, complications, renal function decrease, and length of hospitalization. RESULTS: After matching, 75 patients were included in each group; mean age was 76.6 (± 9) in the TA group and 61.1 (± 12) in the RAPN group, including 69.3% and 76% men respectively. The local recurrence (LR) rate was significantly higher in the TA group than in the PN group (14.6% vs 4%; p = 0.02). The LR rate was 20% (1/5) after microwave ablation, 11.1% (1/9) after radiofrequency ablation, and 14.7% (9/61) after cryoablation. The major complication rate (Clavien-Dindo ≥ 3) was higher following PN than after TA (5.3% vs 0%; p < 0.001). Metastases, eGFR decrease, and length of hospitalization did not differ significantly between the two groups. CONCLUSIONS: The local recurrence rate was significantly higher after thermal ablation; however, thermal ablation resulted in significantly lower rates of complications. Thermal ablation and robotic-assisted partial nephrectomy are effective treatments for T1b renal cancer; however, the local recurrence rate was higher after thermal ablation. KEY POINTS: • The local recurrence rate was significantly higher in the thermal ablation group than in the partial nephrectomy group. • The major complication rate (Clavien-Dindo ≥ 3) was higher following PN than after TA (5.3% vs. 0%; p < 0.001).

Preoperative liver arterial conditioning in patients scheduled for a Mayo Clinic class Ia distal pancreatectomy: embolization or ligation?

BACKGROUND: Liver ischemia may occur during intraoperative common hepatic artery ligation in Mayo Clinic class I distal pancreatectomy with en bloc celiac axis resection (DP-CAR). Preoperative liver arterial conditioning could be used to avoid this outcome. This retrospective study compared arterial embolization (AE) or laparoscopic ligation (LL) of the common hepatic artery before class Ia DP-CAR. METHODS: From 2014 to 2022, 18 patients were scheduled for class Ia DP-CAR after neoadjuvant FOLFIRINOX treatment. Two were excluded due to hepatic artery variation, six underwent AE, ten underwent LL. RESULTS: Two procedural complications occurred in the AE group: an incomplete dissection of the proper hepatic artery and a distal migration of coils in the right branch of the hepatic artery. Neither complication prevented surgery. The median delay between conditioning and DP-CAR was 19 days; decreased to five days in the last six patients. None required arterial reconstruction. Morbidity and 90-day mortality rates were 26.7% and 12.5%, respectively. No patient developed postoperative liver insufficiency after LL. CONCLUSION: Preoperative AE and LL seem comparable in averting arterial reconstruction and postoperative liver insufficiency in patients scheduled for class Ia DP-CAR. However, serious complications that may arise during AE led us to prefer the LL technique.

Hepatic haemophagocytosis in haematology patients with hepatic dysfunction: prognostic impact and contribution of liver biopsy combined with the haemophagocytic syndrome diagnostic score (HScore).

Hepatic dysfunction (HD) is common in patients with haematological malignancies. Hepatic haemophagocytosis (HH) was detected in >50% of liver biopsies taken when HD remained unresolved after standard examination. We aimed to explore the contribution of liver biopsy in patients with both haematological malignancies and HD, describe the population of patients with HH, assess the prognostic impact of HH, and investigate haemophagocytic syndrome diagnostic score (HScore) utility in patients with HH. Between 2016 and 2019, 116 consecutive liver biopsies (76 transjugular, 40 percutaneous) were taken in 110 patients with haematological malignancy and HD (hyperbilirubinaemia, elevated transaminases, and/or cholestasis) and without a clear diagnosis. Liver biopsies were safe and diagnostically efficient. Predominant diagnoses included: HH (56%), graft-versus-host disease (55%), associated infections (24%), sinusoidal obstruction syndrome (15%), and tumoral infiltration (8%). Of patients, 35% were critically ill and 74% were allogeneic haematopoietic stem cell transplantation recipients, while 1-year overall survival (OS) was 35% with HH versus 58% without HH (p = 0.026). The 1-year OS was 24% with a HScore of ≥169 versus 50% with a HScore of <169 (p = 0.019). Liver biopsies are feasible in and contribute significantly to haematology patients with HD. HH occurred frequently and was associated with a poor prognosis. Combined with liver biopsy, the HScore may be helpful in refining haemophagocytic syndrome diagnosis.

Double purse-string telescoped pancreaticogastrostomy is not superior in preventing pancreatic fistula development in high-risk anastomosis: a 6-year single-center case-control study.

PURPOSE: The double purse-string telescoped pancreaticogastrostomy (PG) technique has been suggested as an alternative approach to reduce the risk of postoperative pancreatic fistula (POPF). Its efficacity in high-risk situations has not yet been explored. This study compared the incidence of clinically relevant POPF (CR-POPF) between patients with high-risk anastomosis undergoing PG and those undergoing pancreaticojejunostomy (PJ). METHODS: From 2013 to 2019, 198 consecutive patients with high-risk anastomosis, an updated alternative fistula risk score > 20%, and who underwent pancreatoduodenectomy with the PJ (165) or PG (33) technique were included. Optimal mitigation strategy (external stenting/octreotide omission) was applied for all patients. The primary endpoint was the incidence of CR-POPF. RESULTS: The mean ua-FRS was 33%. CR-POPF (grade B/C) was found in 42 patients (21%) and postoperative hemorrhage in 30 (15%); the mortality rate was 4%. CR-POPF rates were comparable between the PJ (19%) and PG (33%) groups (P = 0.062). The PG group had a higher rate of POPF grade C (24% vs. 10%; P = 0.036), longer operative time (P = 0.019), and a higher transfusion rate (P < 0.001), even after a matching process on ua-FRS. In the multivariate analysis, the type of anastomosis (P = 0.88), body mass index (P = 0.47), or main pancreatic duct diameter (P = 0.7) did not influence CR-POPF occurrence. CONCLUSIONS: For patients with high-risk anastomosis, the double purse-string telescoped PG technique was not superior to the PJ technique for preventing CR-POPF.

An ultra-low-dose protocol for computed tomography-guided lung radiofrequency ablations.

To evaluate the safety and efficacy of ultra-low-dose (ULD) protocol for computed tomography (CT)-guided lung radiofrequency ablation (RFA). Patients who had undergone lung RFA between November 2017 and January 2021 were consecutively and retrospectively included. Thirty patients were treated using a conventional standard protocol (SP), including helical acquisitions with mA automatic adjustment and sequential CT at 80 kVp; and 31, with a ULD protocol defined with helical acquisitions with fixed mA and sequential series at 100 kVp. These parameters were selected from those used for a diagnostic lung low-dose CT scanner. Patient characteristics, dose indicators, technical efficacy (minimal margin [MM], recurrence during follow-up), and complications (pneumothorax, alveolar haemorrhage, and haemoptysis) were recorded. We included 61 patients (median age, 65 [54-73] and 33 women), with no significant differences according to the type of protocol, except for the type of anaesthesia. Even if the number of helical acquisitions did not significantly change, all dose indicators significantly decreased by 1.5-fold-3-fold. The median dose-length-product and effective dose, with their ranges, respectively, were 465 mGy cm (315-554) and 6.5 mSv (4.4-7.8) in the SP group versus 178 mGy cm (154-267) and 2.5 mSv (2.2-3.7) in the ULD group, (p< 001). The ULD group exhibited lower intraoperator variability and better interoperator alignment than those of the SP group. The MM was not significantly different between the two groups (4.6 mm versus 5 mm,p= 16). One local recurrence was observed in each group at 8 months in the SP and at one year in the ULD group (p= 1). The complication rates did not differ significantly. Implementing an ULD protocol during lung RFA may provide similar efficacy, a reduction of dose indicators, and intra- and interoperator variability, without increasing complication rates, compared to those associated with an SP.

Computed tomography-guided microwave ablation of perivascular liver metastases from colorectal cancer: a study of the ablation zone, feasibility, and safety.

OBJECTIVES: To compare the ablation margins and safety of microwave ablation (MWA) of perivascular versus non-perivascular liver metastases from colorectal cancer (CRC) and to determine the risk factors for local tumor progression (LTP) after perivascular MWA. METHODS: Between June 2017 and June 2019, 84 metastases were treated: 39 perivascular (<5 mm from a vessel >3 mm), and 46 non-perivascular. Perivascular metastases were treated with either conventional or optimized protocols (maximum power and/or several heating cycles after repositioning the needle regardless of the initial tumor dimensions). The mean diameter of metastases was 15.4 mm (SD: 7.56). RESULTS: Vascular proximity did not result in a significant difference in ablation margins. The technical success rate, primary efficacy, and secondary efficacy were 90%, 66%, and 83%, respectively. Perivascular location was not a risk factor for time to LTP (p = 0.49), RFS (p = 0.52), or OS (p = 0.54). LTP was statistically related to the presence of a colonic obstruction (p < 0.05), number of metastases at the time of diagnosis (p < 0.05), type of protocol (p < 0.05), ablation margins (p < 0.001) and LTP was proportional to the number of liver resections before MWA (p < 0.05). There was no LTP in tumors ablated with margins over 10 mm. Two grade 4 complications occurred. CONCLUSION: MWA is an effective and safe treatment for perivascular liver metastases from CRC, provided that satisfactory margins are achieved. A maximalist attitude could be related to better local control.

A study of dose indicators during intra-arterial catheter implantation for liver chemotherapy.

The aim of the present study was to describe patient dose indicator levels during intra-arterial catheter (IAC) implantation for liver chemotherapy, and to determine factors affecting the dose indicators. Between January 2017 and January 2019, 61 patients with hepatic metastases from colorectal cancer were retrospectively included. Interventions were carried out in a standardised manner by three experienced radiologists on the same angiographic table without changes in protocol parameters. For each patient, clinical, radiological and dosimetry data were collected, including the air kerma area product (KAP), part of KAP due to the fluoroscopy and fluoroscopy time (FT), total kerma at the reference interventional point and peak skin dose (PSD). Local dose reference levels (RLs) were determined as the third quartile of the patient dose distributions. Univariate and multivariate analysis of factors affecting dose indicators was performed. The mean KAP was 111 Gy cm2, the mean reference point air kerma (Ka,r) was 648 mGy, the mean PSD was 613 mGy, and the mean FT was 3190 s (62% of the KAP). The mean cone beam computed tomography dose was 37.3 ± 11.8 Gy cm2, which accounted for 37% of the KAP. The RL could be proposed taking into account the third quartiles (KAP = 164.6 Gy cm2, Ka,r = 904.5 mGy, FT = 4011 s and standard deviation = 772.7 mGy). The factors affecting dose indicators were related to the patients (sex, cardiovascular risk factors, weight, body mass index), to the vascular anatomies (coeliac trunk angulation) and to the procedures (number of embolised arteries). This study allowed a better understanding of dose indicators and factors affecting these indicators during the implantation of IACs for hepatic chemotherapy, which is a long and difficult procedure. Local dose RLs were determined. Multicentre, multi-equipment studies are necessary.

A single-center experience with pancreatic cystic neuroendocrine tumors.

BACKGROUND: Pancreatic neuroendocrine tumors (PNET) are rare, with a significant malignant potential. This study aimed to determine outcomes of patients with resected PNETs according to the cystic component and confirm the accuracy of preoperative staging. METHODS: From 1997 to 2016, 106 patients underwent resection of PNETs, including 73 purely solid (S-PNETs, 69%), 21 mixed (M-PNETs, 20%), and 12 purely cystic lesions (C-PNETs, 11%). To ensure consistent comparisons of overall (OS) and disease-free (DFS) survival outcomes between the 3 groups, the patients were matched according to the World Health Organization (WHO) grade and tumor height. RESULTS: Overall, the rate of correlation between the preoperative and pathological diagnoses was low in the C-PNET group (33%, P = 0.03). None of the 24 patients (23%) with metastatic disease at the time of surgery were in the C-PNET group. Furthermore, significantly more parenchyma-sparing resections (P = 0.039) and fewer enlarged resections (P = 0.019) were achieved in the C-PNET group. C-PNET group had a significantly lower node invasion rate than the S-PNET and M-PNET groups (8% vs. 41% and 24%, P = 0.004). Although median OS was comparable in all 3 groups before (P = 0.3) and after (P = 0.18) matching, higher median DFS was observed in the C-PNET group than in the other groups after matching (P = 0.038). CONCLUSION: C-PNET was associated with a better prognosis than PNET with a solid component. The results support a wait-and-see policy in cases wherein a reliable preoperative diagnosis remains challenging.

Computed tomography-guided percutaneous cryoablation of T1b renal tumors: safety, functional and oncological outcomes.

Purpose: To evaluate the safety, functional and oncological outcomes associated with percutaneous cryoablation of stage T1b renal cell carcinoma (RCC). Materials and methods: Institutional database was reviewed to identify patients treated by percutaneous CT-guidance cryoablation between 2013 and 2018 for biopsy-proven RCC tumors measuring 4.1-7.0 cm. The main outcome parameters analyzed were primary and secondary technique efficacy, progression-free survival (PFS), cancer-specific survival (CSS), loss of estimated glomerular filtration rate (eGFR) and complications. PFS and CSS were estimated by the Kaplan-Meier method. Complications were graded by the Clavien-Dindo system. Results: Twenty-three consecutive patients were included (mean tumor diameter: 45.6 ± 6.2 mm; mean RENAL score: 8.1 ± 1.8). The technical success rate was 95.7%. Primary and secondary technique efficacy rates were 86.3 and 100%, respectively. Three patients found to have incomplete ablations at 3 months were successfully treated by repeat cryoablation. Median duration follow-up was 11 months (range: 3-33). Imaging showed PFS to be 85.7% at 6 months, 66.7% at 12 months and 66.7% at 24 months. One patient with a local recurrence at 12 months was treated by radical nephrectomy. One patient died from progression of disease within 12 months. One patient reported a complication grade ≥ II (4.3%). Mean eGFR loss was 4.4 ± 8.5 ml/min/1.73m2, which was significantly higher among those treated for central tumors (p < .05). Conclusion: Cryoablation for stage T1b renal tumors is technically feasible, with favorable oncological and perioperative outcomes. Longer-term studies are needed to verify our findings.

Is progression in the future liver remnant a contraindication for second-stage hepatectomy?

BACKGROUND: Two-stage hepatectomy (TSH) strategy is used to treat patients with bilobar colorectal liver metastasis (CLM). However, many patients do not undergo the second hepatectomy owing to disease progression in the future liver remnant (FLR) after portal vein embolization (PVE). This study aimed to assess the impact of disease progression in the FLRs of patients who completed the first hepatectomy. METHODS: 68 consecutive patients underwent the first hepatectomy followed by PVE. Six patients (9%) dropped out after the PVE (two-stage failed [TSF] group) because of unresectable hepatic or general disease progression. Seventeen patients (25%) completed their second hepatectomy despite disease progression in the FLR (new CLM [nCLM] group) as it was considered resectable, while 45 patients (66%) underwent the second hepatectomy (control group). RESULTS: The 5-year overall survival rates in the TSF, nCLM, and control groups were 0%, 7%, and 60%, respectively (P < 0.001). The median overall survival times between the TSF and nCLM groups were 26 months and 42 months (P = 0.005). Patients in the nCLM group whose hepatic disease progression was detected preoperatively versus intraoperatively had comparable survival rates. CONCLUSION: Resectable hepatic disease progression in the FLR after PVE should not be considered a contraindication for the second hepatectomy.

Impact of radiotherapy in the management of locally advanced extrahepatic cholangiocarcinoma.

BACKGROUND: Optimal therapy for patients with unresectable locally advanced extrahepatic cholangiocarcinoma (ULAC) remains controversial. We analysed the role of radiotherapy in the management of such tumors. METHODS: We retrospectively reviewed the charts of patients treated in our institution with conformal-3D external-beam-radiotherapy (EBRT) with or without concurrent chemotherapy. RESULTS: Thirty patients were included: 24 with a primary tumor (group 1) and 6 with a local relapse (group 2). Toxicity was low. Among 25 patients assessable for EBRT response, we observed 9 complete responses, 4 partial responses, 10 stabilisations, and 2 progressions. The median follow-up was 12 months. Twenty out of 30 patients (66%) experienced a relapse, which was metastatic in 75% of cases in the whole series, 87% in group 1, 60% in group 2 (p = 0.25). Twenty-eight patients (93%) died of relapse or disease complications. Median overall survivals in the whole group and in group 1 or 2 were respectively 12, 11 and 21 months (p = 0.11). The 1-year and 3-year progression-free survivals were respectively 38% and 16% in the whole series; 31% and 11% in group 1, 67% and 33% in group 2 (p = 0.35). CONCLUSION: EBRT seems efficient to treat ULAC, with acceptable toxicity. For primary disease, the high rate of metastatic relapse suggests to limit EBRT to non-progressive patients after induction chemotherapy.

Assessment of biological effect of nab-paclitaxel combined with gemcitabine, using contrast enhanced ultrasonography and elastography, in advanced pancreatic ductal carcinoma: A single-center pilot study.

EUS associated with contrast-enhanced harmonic EUS (CH-EUS) and EUS elastography (EUS-E) are used in clinical practice to assess pancreatic tumor at the diagnosis. In case of pancreatic ductal adenocarcinoma (PDAC) with liver metastasis, nab-paclitaxel combined with gemcitabine is a first-line treatment option. We aimed to assess the modification of PDAC microenvironment induced by the combination of nab-paclitaxel with gemcitabine, by endoscopic ultrasonography techinics. This single center phase III study conducted between February 2015 and June 2016 included patients with pancreatic adenocarcinoma with mesurable liver metastasis and no prior cancer treatment fit for two cycles of nab-paclitaxel combined with gemcitabine. We aimed to perform EUS with CH-EUS and EUS-E of the pancreatic tumor, CT scan and contrast enhanced ultrasonogram (CE-US) of a reference liver metastasis, before and after the two cylces of chemotherapy. Primary end point was modification of vascularizaion of primary tumor and a reference liver metastasis. Secondary end points were modification of stromal content, safety profile of drug combination and tumor response rate. Sixteen patients were analyzed, but only 13 received two cycled of chemotherapy (CT) (toxicity [n = 1] or death [n = 2]). There was no statistical modification induced by CT concering vascularity of primary tumor (time to maximum intensity P = 0.24, value of maximum intensity P = 0.71, hypoechogenic aspect generated by injection of contrast enhancing agent), vascularity of a reference liver metastasis (time to maximum intensity P = 0.99, value of maximum intensity P = 0.71) and tumor elasticity (P = 0.22). Eleven patients had tumor response assessement, 6/11 (54%) had measurable disease response 4/11 (36%) with partial responses and 2/11 (18%) with stable disease. All other patients showed disease progression. No serious side effects occurred, 6/11 patients had a dose adjustment. We did not show significant modification of vascularity and elasticity but these results should be taken with caution because of important limitations.

Transarterial chemoembolization (TACE) for neuroendocrine liver metastasis (NELM): Predictive value of volumetric arterial enhancement (VAE) on baseline MRI.

BACKGROUND: Neuroendocrine tumors (NETs) belong to a rare family of tumors whose incidence has increased significantly over the past 50 years. PURPOSE: To evaluate the prognostic value of volumetric arterial enhancement (VAE) on baseline magnetic resonance imaging (MRI) for patients with neuroendocrine liver metastasis (NELM) treated using transarterial chemoembolization (TACE). MATERIAL AND METHODS: Between October 2012 and December 2018, VAE in 37 patients was measured with a semi-automatic volume of Interest (VOI) on subtracted T1 sequence in the arterial phase. Patients underwent 1-3 sectoral lipiodol TACE. Radiologic response using modified Response Evaluation Criteria in Solid Tumors (mRECIST) at the treatment cycle end and progression free survival were determined. RESULTS: Median age was 68.0 (60.0; 73.0). Twenty-three patients (62%) had a partial response, 10 (27%) had stable disease, four (11%) had progressive disease. VAE was a significant (P<0.05) predictor of radiologic response. Median progression free survival was 13 months (IC 95: 8; 16). In univariate analysis, significant predictors of local progression were alkaline phosphatase (AP) (P=0.035), Ki-67 index (P=0.014), and VAE (P<0.01). VAE over 500ms and Ki-67 index over 3%were risk factors of progression (P=<0.01) in multivariate analysis. CONCLUSION: VAE before TACE could be predictive of radiologic response and could be related to oncologic outcomes in patients with NELM.

Evaluation of preventive tract embolization with standardized gelatin sponge slurry on chest tube placement rate after CT-guided lung biopsy: a propensity score analysis.

BACKGROUND: To evaluate the effect of tract embolization (TE) with gelatin sponge slurries during a percutaneous lung biopsy on chest tube placement and to evaluate the predictive factors of chest tube placement. METHODS: Percutaneous CT-guided lung biopsies performed with (TE) or without (non-TE) tract embolization or between June 2012 and December 2021 at three referral tertiary centers were retrospectively analyzed. The exclusion criteria were mediastinal biopsies, pleural tumors, and tumors adjacent to the pleura without pleural crossing. Variables related to patients, tumors, and procedures were collected. Univariable and multivariable analyses were performed to determine risk factors for chest tube placement. Furthermore, the propensity score matching analysis was adopted to yield a matched cohort. RESULTS: A total of 1157 procedures in 1157 patients were analyzed, among which 560 (48.4%) were with TE (mean age 66.5 ± 9.2, 584 men). The rates of pneumothorax (44.9% vs. 26.1%, respectively; p < 0.001) and chest tube placement (4.8% vs. 2.3%, respectively; p < 0.001) were significantly higher in the non-TE group than in the TE group. No non-targeted embolization or systemic air embolism occurred. In the whole population, two protective factors for chest tube placement were found in univariate analysis: TE (OR 0.465 [0.239-0.904], p < 0.05) and prone position (OR 0.212 [0.094-0.482], p < 0.001). These data were confirmed in multivariate analysis (p < 0.001 and p < 0.0001 respectively). In the propensity matched cohort, TE reduces significatively the risk of chest tube insertion (OR = 0.44 [0.21-0.87], p < 0.05). CONCLUSIONS: The TE technique using standardized gelatin sponge slurry reduces the need for chest tube placement after percutaneous CT-guided lung biopsy. CRITICAL RELEVANCE STATEMENT: The tract embolization technique using standardized gelatin sponge slurry reduces the need for chest tube placement after percutaneous CT-guided lung biopsy. KEY POINTS: 1. Use of tract embolization with gelatine sponge slurry during percutaneous lung biopsy is safe. 2. Use of tract embolization significantly reduces the risk of chest tube insertion. 3. This is the first multicenter study to show the protective effect of tract embolization on chest tube insertion.

Peak Risk of Recurrence Occurs during the First Two Years after a Pancreatectomy in Patients Receiving Neoadjuvant FOLFIRINOX.

No codified/systematic surveillance program exists for borderline/locally advanced pancreatic ductal carcinoma treated with neoadjuvant FOLFIRINOX and a secondary resection. This study aimed to determine the trend of recurrence in patients who were managed using such a treatment strategy. From 2010, 101 patients received FOLFIRINOX and underwent a pancreatectomy, in a minimum follow-up of 5 years. Seventy-one patients (70%, R group) were diagnosed with recurrence after a median follow-up of 11 months postsurgery. In the multivariable analysis, patients in the R-group had a higher rate of weight loss (p = 0.018), higher carbohydrate antigen (CA 19-9) serum levels at diagnosis (p = 0.012), T3/T4 stage (p = 0.017), and positive lymph nodes (p < 0.01) compared to patients who did not experience recurrence. The risk of recurrence in patients with T1/T2 N0 R0 was the lowest (19%), and all recurrences occurred during the first two postoperative years. The peak risk of recurrence for the entire population was observed during the first two postoperative years. The probability of survival decreased until the second year and rebounded to 100% permanently, after the ninth postoperative year. Close monitoring is needed at reduced intervals during the first 2 years following a pancreatectomy and should be extended to later than 5 years for those with unfavorable pathological results.

Is MRI-Linac helpful in SABR treatments for liver cancer?

Objective: To determine the MRI-Linac added value over conventional image-guided radiation therapy (IGRT) in liver tumors Stereotactic ablative radiation therapy (SABR). Materials and methods: We retrospectively compared the Planning Target Volumes (PTVs), the spared healthy liver parenchyma volumes, the Treatment Planning System (TPS) and machine performances, and the patients' outcomes when using either a conventional accelerator (Versa HD®, Elekta, Utrecht, NL) with Cone Beam CT as the IGRT tool or an MR-Linac system (MRIdian®, ViewRay, CA). Results: From November 2014 to February 2020, 59 patients received a SABR treatment (45 and 19 patients in the Linac and MR-Linac group, respectively) for 64 primary or secondary liver tumors. The mean tumor size was superior in the MR-Linac group (37,91cc vs. 20.86cc). PTV margins led to a median 74%- and 60% increase in target volume in Linac-based and MRI-Linac-based treatments, respectively. Liver tumor boundaries were visible in 0% and 72% of the cases when using CBCT and MRI as IGRT tools, respectively. The mean prescribed dose was similar in the two patient groups. Local tumor control was 76.6%, whereas 23.4% of patients experienced local progression (24.4% and 21.1% of patients treated on the conventional Linac and the MRIdian system, respectively). SABR was well tolerated in both groups, and margins reduction and the use of gating prevented ulcerous disease occurrence. Conclusion: The use of MRI as IGRT allows for the reduction of the amount of healthy liver parenchyma irradiated without any decrease of the tumor control rate, which would be helpful for dose escalation or subsequent liver tumor irradiation if needed.

Percutaneous tumor ablation versus image guided robotic-assisted partial nephrectomy for cT1b renal cell carcinoma: a comparative matched-pair analysis (UroCCR 80).

BACKGROUND: Partial nephrectomy (PN) is the gold standard treatment for cT1b renal tumors. Percutaneous guided thermal ablation (TA) has proven oncologic efficacy with low morbidity for the treatment of small renal masses (<3 cm). Recently, 3D image-guided robot-assisted PN (3D-IGRAPN) has been described, and decreased perioperative morbidity compared to standard RAPN has been reported. Our objective was to compare two minimally invasive image-guided nephron-sparing procedures (TA vs. 3D-IGRAPN) for the treatment of cT1b renal cell carcinomas (4.1-7 cm). METHODS: Patients treated with TA and 3D-IGRAPN for cT1b renal cell carcinoma, prospectively included in the UroCCR database (NCT03293563), were pair-matched for tumor size, pathology, and RENAL score. The primary endpoint was the local recurrence rate between the two groups. Secondary endpoints included metastatic evolution, perioperative complications, decrease in renal function, and length of hospitalization. RESULTS: A total of 198 patients were included and matched into two groups of 72 patients. The local recurrence rate was significantly higher in the TA group than that in the 3D-IGRAPN group (4.2% vs. 15.2%, P=0.04). Metastatic evolution and perioperative outcomes such as major complications, eGFR decrease, and length of hospitalization did not differ significantly between the two groups. CONCLUSIONS: 3D-IGRAPN resulted in a significantly lower local recurrence rate and comparable rates of complications and metastatic evolution compared with thermal ablation.

Repeated Multimodality Ablative Therapies for Oligorecurrent Pulmonary Metastatic Disease.

Stereotactic body radiotherapy (SBRT) and percutaneous thermal ablation (TA) are alternatives to surgery for the management of pulmonary oligometastases. In this collaborative work, we retrospectively analyzed patients who had undergone iterative focal ablative treatments of pulmonary oligometastases. We hypothesized that repeated ablative therapies could benefit patients with consecutive oligometastatic relapses. Patients treated with SBRT and/or TA for pulmonary oligometastases in two French academic centers between October 2011 and November 2016 were included. A total of 102 patients with 198 lesions were included; 45 patients (44.1%) received repeated focal treatments at the pulmonary site for an oligorecurrent disease (the "multiple courses" group). Median follow-up was 22.5 months. The 3-year overall survival rates of patients who had a single treatment sequence (the "single course" group) versus the "multiple courses" were 73.9% and 78.8%, respectively, which was not a statistically significant difference (p = 0.860). The 3-year systemic therapy-free survival tended to be longer in the "multiple courses" group (50.4%) than in the "single course" group (44.7%) (p = 0.081). Tolerance of repeated treatments was excellent with only one grade 4 toxicity. Thereby, multimodality repeated ablative therapy is effective in patients with pulmonary oligorecurrent metastases. This strategy may delay the use of more toxic systemic therapy.

New MR imaging criteria with a diffusion-weighted sequence for the diagnosis of hepatocellular carcinoma in chronic liver diseases.

BACKGROUND & AIMS: To propose MRI criteria with a diffusion-weighted imaging (DWI) sequence for the diagnosis of hepatocellular carcinoma (HCC). METHODS: Patients, who underwent liver MRI with contrast-enhanced sequences and DWI between 2004 and 2008 and who had at least one confirmed HCC of at least 10mm, were included. Index diagnostic criteria were: (1) enhancement in the arterial-dominant phase and washout in the portal venous and/or equilibrium phases; (2) enhancement in the arterial-dominant phase and hyperintensity on DWI; (3) enhancement in the arterial-dominant phase and washout in the portal venous and/or equilibrium phases or hyperintensity on DWI. Two radiologists independently reviewed the corresponding sets of sequences (DWI alone; T1-weighted sequence before and after dynamic injection of gadolinium chelates; combined DWI-T1-weighted sequence). Inter-observer agreement and sensitivity were determined per nodule. RESULTS: Ninety-one patients were included (109 HCCs). The sensitivity of conventional MRI criteria for the diagnosis of HCC was 59.6% for both radiologists. The sensitivity of enhancement in the arterial-dominant phase and hyperintensity on DWI was 77.1% or 76.1%, depending on the radiologist. The sensitivity of enhancement in the arterial-dominant phase and washout in the portal venous and/or equilibrium phases or hyperintensity on DWI was 84.4% or 85.3%, depending on the radiologist. The inter-observer agreement for the latter was very good (kappa coefficient 0.82). These results were consistent in HCCs smaller than 20mm. CONCLUSIONS: The proposed criteria, based on the characteristics of lesions after gadolinium chelate administration and hyperintensity on DWI, significantly increased the sensitivity for the diagnosis of HCC compared to conventional criteria, regardless of tumor size.

Efficacy of Tract Embolization After Percutaneous Pulmonary Radiofrequency Ablation.

PURPOSE: To evaluate the efficacy of tract embolization technique using gelatin sponge slurry with iodinated contrast medium (GSSI) to reduce the incidence of pneumothorax and chest tube placement after computed tomography-guided lung radiofrequency ablation (RFA). MATERIALS AND METHODS: In this single-institute retrospective study, we examined all patients with metastatic cancer treated from January 2016 to December 2019 by interventional radiologists with computed tomography-guided lung RFA. Since 2017 in our institution, we have applied a tract embolization technique using GSSI for all RFA. Patients were included into those who underwent lung RFA performed either with GSSI (Group A) or without GSSI (Group B). Univariate and multivariate analyses were performed between the two groups to identify risk factors for pneumothorax and chest tube placement, including patient demographics and lesion characteristics. RESULTS: This study included 116 patients (54 men, 62 women; mean age, 65 ± 11 years) who underwent RFA. Group A comprised 71 patients and Group B comprised 45 patients. Patients who underwent tract embolization had a significantly lower incidence of pneumothorax (Group A, 34% vs. Group B, 62%; p < 0.001) and chest tube insertion (Group A, 10% vs. Group B, 29%; p < 0.01). No embolic complications occurred. The hospitalization stay was significantly shorter in patients who underwent tract embolization (mean, 1.04 ± 0.2 days; p = 0.02). CONCLUSION: Tract embolization after percutaneous lung RFA significantly reduced the rate of post-RFA pneumothorax and chest tube placement and was safer than the standard lung RFA technique.