Cranial sonolucent prosthesis: a window of opportunity for neuro-oncology (and neuro-surgery).

INTRODUCTION: Ultrasound (US) is a versatile technology, able to provide a real-time and multiparametric intraoperative imaging, and a promising way to treat neuro-oncological patients outside the operating room. Anyhow, its potential is limited both in imaging and therapeutic purposes by the existence of the bone shielding. To enhance the spectrum of uses, our group has designed a dedicated US-translucent cranial prosthesis. Herein, we provide the proof of concept of a long-term US-based follow-up and a potential bedside therapeutic exploitation of US. METHODS: The prosthesis was first implanted in a cadaveric specimen to record any issue related to the cranioplasty procedure. Hence, the device was implanted in a patient undergoing surgery for a multi-recurrent anaplastic oligodendroglioma. US multiparametric scans through the device were acquired at 3, 6, 9, and 30 months after the procedure. RESULTS: The prosthesis could be modeled and implanted through ordinary instruments, with no concerns over safety and feasibility. Trans-prosthesis multiparametric US imaging was feasible, with image quality comparable to intraoperative US. Long-term follow-up in an outpatient setting was possible with no adverse events. Trans-prosthesis mechanical interaction with microbubbles was also feasible during follow-up. CONCLUSIONS: This report provides the first proof of concept for a potential breakthrough in the management of neuro-oncological patients. Indeed, through the implantation of an artificial acoustic window, the road is set to employ US both for a more dynamic long-term follow-up, and for US-guided therapeutic applications.

Image-guided thermal ablation in autonomously functioning thyroid nodules. A retrospective multicenter three-year follow-up study from the Italian Minimally Invasive Treatment of the Thyroid (MITT) Group.

OBJECTIVES: To report the results of a multicenter retrospective evaluation of the clinical outcomes of thermal ablation (TA) in a large series of autonomously functioning thyroid nodules (AFTN) with a follow-up protracted up to 3 years. METHODS: Patients treated with single TA for an AFTN in Italy were included. Changes in nodule volume, TSH values, and ongoing anti-thyroid therapy were assessed at the 2-, 6-, 12-, 24-, and 36-month follow-up controls. Complications and need of any additional therapy after TA were also registered. RESULTS: A total of 361 patients (244 females, 117 males, median age 58 years, IQR 46-70 years) were included. Nodule volume was significantly reduced at all time points (p < 0.001) (median volume reduction 58% at 6-month and 60% at 12-month). Serum TSH values increased significantly at all time points. After TA, anti-thyroid therapy was withdrawn in 32.5% of patients at 2 months, in 38.9% at 6 months, and in 41.3% at 12 months. A significant difference in the rate of patients who withdrawn medical therapy at 12 months was registered between small (< 10 mL) (74%), medium (49%), or large (> 30 mL) nodules (19%). A single major complication occurred (0.25%). Additional treatments were needed in 34/361 (9.4%) of cases including 4 (1.1%) surgical treatment. CONCLUSIONS: Image-guided thermal ablation offers a further safe and effective therapeutic option in patients with AFTN. Clinical outcomes are significantly more favorable in small than in large size AFTN. KEY POINTS: • Thermal ablations (TA) can be safely and effectively used in patients with autonomously functioning thyroid nodules (AFTN). • TA results in a clinically significant nodule volume reduction that is paralleled by TSH level normalization and anti-thyroid drug therapy discontinuation (after TA anti-thyroid therapy was withdrawn in 41.3% at 12 months). • Clinical outcomes after TA are more favorable in small nodules, and when a large amount of thyroid nodule tissue is ablated.

Volumetric assessment of the periablational safety margin after thermal ablation of colorectal liver metastases.

OBJECTIVES: To retrospectively assess the periablational 3D safety margin in patients with colorectal liver metastases (CRLM) referred for stereotactic radiofrequency ablation (RFA) and to evaluate its influence on local treatment success. METHODS: Forty-five patients (31 males; mean age 64.5 [range 31-87 years]) with 76 CRLM were treated with stereotactic RFA and retrospectively analyzed. Image fusion of pre- and post-interventional contrast-enhanced CT scans using a non-rigid registration software enabled a retrospective assessment of the percentage of predetermined periablational 3D safety margin and CRLM successfully ablated. Periablational safety zones (1-10 mm) and percentage of periablational zone ablated were calculated, analyzed, and compared with subsequent tumor growth to determine an optimal safety margin predictive of local treatment success. RESULTS: Mean overall follow-up was 36.1 ± 18.5 months. Nine of 76 CRLMs (11.8%) developed local tumor progression (LTP) with mean time to LTP of 18.3 ± 11.9 months. Overall 1-, 2-, and 3-year cumulative LTP-free survival rates were 98.7%, 90.6%, and 88.6%, respectively. The periablational safety margin assessment proved to be the only independent predictor (p < 0.001) of LTP for all calculated safety margins. The smallest safety margin 100% ablated displaying no LTP was 3 mm, and at least 90% of a 6-mm circumscribed 3D safety margin was required to achieve complete ablation. CONCLUSIONS: Volumetric assessment of the periablational safety margin can be used as an intraprocedural tool to evaluate local treatment success in patients with CRLM referred to stereotactic RFA. Ablations achieving 100% 3D safety margin of 3 mm and at least 90% 3D safety margin of 6 mm can predict treatment success. KEY POINTS: • Volumetric assessment of the periablational safety margin can be used as an intraprocedural tool to evaluate local treatment success following thermal ablation of colorectal liver metastases. • Ablations with 100% 3D periablational safety margin of 3 mm and ablations with at least 90% 3D safety margin of 6 mm can be considered indications of treatment success. • Image fusion of pre- and post-interventional CT scans with the software used in this study is feasible and could represent a useful tool in daily clinical practice.

Real-time US/cone-beam CT fusion imaging for percutaneous ablation of small renal tumours: a technical note.

INTRODUCTION: Fusion imaging is gaining attention as an imaging technique to assist minimally invasive tumour ablation. Ultrasound (US) and computed tomography (CT) are the most common imaging modalities to guide thermal ablation of renal tumours, yet cone-beam CT (CBCT) has recently been described to successfully assist percutaneous renal interventions. Our goal was to evaluate primary technical success and correct lesion targeting of US/CBCT fusion imaging to guide the ablation of kidney masses < 2 cm in a small group of patients. MATERIAL AND METHODS: Six renal lesions (maximum diameter 11-17 mm) were treated with RFA in 5 different patients using real-time US/CBCT. Fusion imaging was used to identify and monitor tumour ablation. Demographics, tumour characteristics and mean serum creatinine levels were recorded before and after the procedure. Primary technical success and correct lesion targeting represented the main endpoints of the study. Primary technique efficacy was confirmed at 1-month and 3-month contrast-enhanced CT follow-ups. RESULTS: In all cases, a confident US/CBCT synchronisation was reached and allowed for a correct targeting and a successful percutaneous ablation. Primary technique efficacy was 100%. No recurrence was observed at the follow-up that ranged from 8 to 26 months (mean 16 months). CONCLUSIONS: US/CBCT fusion proved to be a viable method to precisely guide safe and effective percutaneous thermal ablation in patients with small renal tumours, especially when hardly detectable on US. KEY POINTS: • US/CBCT fusion imaging for renal ablation is safe and feasible. • US/CBCT fusion imaging allows for an improved targeting and complete ablation of small RCC with poor US-conspicuity.

Real-Time US-CT fusion imaging for guidance of thermal ablation in of renal tumors invisible or poorly visible with US: results in 97 cases.

PURPOSE: To assess the capability of ultrasound-computed tomography (US-CT) fusion imaging to guide a precise targeting of renal tumors invisible or poorly visible with US. MATERIALS AND METHODS: From 2016 renal tumors poorly visible or inconspicuous/invisible at US were treated at our institution with the guidance of US/CT fusion in a room equipped with CT scanner. Feasibility of the procedure, accuracy of targeting, complications, and technique efficacy were evaluated. RESULTS: Of 227 patients treated from 2016 to March 2020, 91 patients (65 males and 26 females, mean age 68.5 ± 10.1 years) with 97 renal lesions (mean maximum diameter 21.6 ± 9.4 mm) inconspicuous/invisible (29/97, 29.9%) or poorly visible (68/97, 70.1%) at US underwent treatment under US-CT fusion guidance. US-CT fusion imaging guidance was always technically feasible and enabled correct targeting in 97/97/(100%) of cases. Technical success was achieved in 93/97 lesions (95.9%). Three lesions were retreated during the same ablative session, while 1 was retreated in a subsequent session. Thus, primary efficacy was achieved in one session in 96/97 (98.9%) cases and secondary efficacy in 97/97 (100%) cases. CONCLUSION: US-CT image fusion guidance allows for a correct tumor targeting of renal tumors poorly visible or inconspicuous/invisible with US alone, with a high rate of technical success and technique efficacy.

US-guided laser treatment of parathyroid adenomas.

Objective: To determine the clinical efficacy of laser ablation for the tredatment of primary hyperparathyroidism (pHPT).Materials and methods: Twelve patients with pHPT were treated with laser ablation. Energy was administered by means of 1.5 m optical fibers percutaneously placed into the target via 21 G needles. A laser ablation unit (EchoLaser X4, Esaote) applied 3 W power for 400-600 s/fiber/insertion to a total 3600-9000 Joules of energy. Patient serum parathyroid hormone (PTH) and calcium levels were checked at baseline and thereafter every 6 months. Patients were followed-up for 2 years with serologic and contrast-enhanced ultrasound. Therapeutic success was defined as normal PTH and calcium levels together with disappearance of nodule-related symptoms.Results: All procedures were performed in single session. Immediately following ablation, contrast enhanced ultrasound confirmed that all but one target had become avascular (technical success rate 11/12; 92%), remaining avascular at all follow-up ultrasound examinations, thereafter. The mean volume of parathyroid nodules decreased from 0.54 cc to 0.36 cc (72.0%). Serum PTH and calcium levels were significantly lower at 1, 12 and 24 m compared to baseline (p < 0.01). By 6 m, PTH and calcium returned to normal and were stable until 24 m in all successfully treated patients. All cases of hyperparathyroid-related symptoms resolved by 6 m (ostealgia [n = 5], repeated renal colic [n = 5], vomiting [n = 3]). Only one patient (8%) reported transient dysphonia as a minor complication.Conclusion: Laser ablation of enlarged, symptomatic parathyroid glands is safe and well-tolerated and can produce long-term, sustained reduction of serum PTH and calcium levels.

Percutaneous radiofrequency ablation of HCC: reduced ablation duration and increased ablation size using single, internally cooled electrodes with an optimized pulsing algorithm.

PURPOSE: To assess the use of optimized radiofrequency (RF) to achieve larger, spherical ablation volumes with short application duration for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Twenty-two patients (M:F = 17:5, median age 69.6 year, range 63-88) with 28 HCCs due to HCV + liver cirrhosis underwent RFA. 20/28 (71.4%) were tumors ≤3cm diameter, and 8/28 (28.6%) ranged from 3.2 to 4.2 cm. RF was applied using up to 2500mA via an optimized pulsing algorithm with real-time ultrasound monitoring to detect hyperechogenic changes. Single insertions of an internally cooled electrode were performed using exposed tips of 2 or 3 cm for 13 HCCs and 4 cm for 15 HCCs. All patients were followed-up for a minimum of 5 years with contrast-enhanced computed tomography (CECT). RESULTS: Technical success was achieved without adverse events in all cases. The mean ablation time was 8.5 ± 2.6 min. In 21/28 (75%), ablation duration ranged from 3 to 9 min, with 12 min duration applied in only 7/28 (25%). Mean coagulation diameters were 2.4 ± 0.14, 3.3 ± 0.62, and 4.4 ± 1.0, for 2, 3 and 4 cm electrodes, respectively (p < 0.01). The sphericity index was 74.9 ± 12.8 for 4 cm electrodes and 81.9 ± 8.0 for shorter electrodes (p = 0.091). At 5-year follow-up, no tumor ≤3 cm had recurrence and only 2/8 (25%) >3 cm tumors developed local progression. One patient had multifocal disease with no local progression. CONCLUSION: Efficient delivery of RF energy can considerably decrease the ablation time in many instances while achieving larger, relatively spherical, and reproducible areas of ablation with extremely low rates of local tumor progression and adverse events.

A novel software platform for volumetric assessment of ablation completeness.

PURPOSE: To retrospectively evaluate the accuracy of a novel software platform for assessing completeness of percutaneous thermal ablations. MATERIALS & METHODS: Ninety hepatocellular carcinomas (HCCs) in 50 patients receiving percutaneous ultrasound-guided microwave ablation (MWA) that resulted in apparent technical success at 24-h post-ablation computed tomography (CT) and with ≥1-year imaging follow-up were randomly selected from a 320 HCC ablation database (2010-2016). Using a novel volumetric registration software, pre-ablation CT volumes of the HCCs without and with the addition of a 5 mm safety margin, and corresponding post-ablation necrosis volumes were segmented, co-registered and overlapped. These were compared to visual side-by-side inspection of axial images. RESULTS: At 1-year follow-up, CT showed absence of local tumor progression (LTP) in 69/90 (76.7%) cases and LTP in 21/90 (23.3%). For HCCs classified by the software as "incomplete tumor treatments", LTP developed in 13/17 (76.5%) and all 13 (100%) of these LTPs occurred exactly where residual non-ablated tumor was identified by retrospective software analysis. HCCs classified as "complete ablation with <100% 5 mm ablative margins" had LTP in 8/49 (16.3%), while none of 24 HCCs with "complete ablation including 100% 5 mm ablative margins" had LTP. Differences in LTP between both partially ablated HCCs vs completely ablated HCCs, and ablated HCCs with <100% vs with 100% 5 mm margins were statistically significant (p < .0001 and p = .036, respectively). Thus, 13/21 (61.9%) incomplete tumor treatments could have been detected immediately, were the software available at the time of ablation. CONCLUSIONS: A novel software platform for volumetric assessment of ablation completeness may increase the detection of incompletely ablated tumors, thereby holding the potential to avoid subsequent recurrences.

Minimally-invasive treatments for benign thyroid nodules: a Delphi-based consensus statement from the Italian minimally-invasive treatments of the thyroid (MITT) group.

Benign thyroid nodules are a common clinical occurrence and usually do not require treatment unless symptomatic. During the last years, ultrasound-guided minimally invasive treatments (MIT) gained an increasing role in the management of nodules causing local symptoms. In February 2018, the Italian MIT Thyroid Group was founded to create a permanent cooperation between Italian and international physicians dedicated to clinical research and assistance on MIT for thyroid nodules. The group drafted this list of statements based on literature review and consensus opinion of interdisciplinary experts to facilitate the diffusion and the appropriate use of MIT of thyroid nodules in clinical practice. (#1) Predominantly cystic/cystic symptomatic nodules should first undergo US-guided aspiration; ethanol injection should be performed if relapsing (level of evidence [LoE]: ethanol is superior to simple aspiration = 2); (#2) In symptomatic cystic nodules, thermal ablation is an option when symptoms persist after ethanol ablation (LoE = 4); (#3) Double cytological benignity confirmation is needed before thermal ablation (LoE = 2); (#4) Single cytological sample is adequate in ultrasound low risk (EU-TIRADS ≤3) and in autonomously functioning nodules (LoE = 2); (#5) Thermal ablation may be proposed as first-line treatment for solid, symptomatic, nonfunctioning, benign nodules (LoE = 2); (#6) Thermal ablation may be used for dominant lesions in nonfunctioning multinodular goiter in patients refusing/not eligible for surgery (LoE = 5); (#7) Clinical and ultrasound follow-up is appropriate after thermal ablation (LoE = 2); (#8) Nodule re-treatment can be considered when symptoms relapse or partially resolve (LoE = 2); (#9) In case of nodule regrowth, a new cytological assessment is suggested before second ablation (LoE = 5); (#10) Thermal ablation is an option for autonomously functioning nodules in patients refusing/not eligible for radioiodine or surgery (LoE = 2); (#11) Small autonomously functioning nodules can be treated with thermal ablation when thyroid tissue sparing is a priority and ≥80% nodule volume ablation is expected (LoE = 3).

Ultrasound and cone beam CT fusion for liver ablation: technical note.

PURPOSE: To assess the feasibility of fusion imaging between intraprocedural ultrasound (US) and contrast-enhanced cone-beam CT (CBCT) for small (< 2 cm) hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Six patients (five males, one female, age range 58-80, mean 69 years), with small (mean diameter 16.8 mm) HCC poorly visible at US underwent percutaneous microwave ablation under US/CBCT fusion guidance. During general anesthesia with apnea control, a contrast- enhanced CBCT was acquired with an active tracker. Subsequently, real time US images were fused with CBCT images, and treatment performed under fusion imaging guidance. Feasibility of fusion imaging and percutaneous ablation were assessed, correct targeting (distance from center of tumor and center of ablation area <5 mm) and one-month primary technical efficacy were evaluated. Major and minor complications as well as overall procedural time were recorded. RESULTS: US/CBCT fusion was feasible in all cases, allowing for completion of the treatment as previously planned (technical success 100%). Correct targeting was achieved in 4/6 cases (66%), while in two cases, center of tumor and center of ablated area were respectively 7 and 8 mm distant. At 1 month CT scan, all tumors were completely ablated (primary technical efficacy 100%). No major or minor complications occurred. Mean overall procedure time was 127 min. CONCLUSIONS: US/CBCT fusion is a feasible technique for liver ablation, and might represent a useful tool to increase the correct targeting of poorly US-visible HCC nodules in the angio suite.

Aggressive and Multidisciplinary Local Approach to Iterative Recurrences of Colorectal Liver Metastases.

BACKGROUND: Liver resection (LR) of colorectal metastases is associated with high recurrence risk. Aggressive local retreatment is advocated, but further recurrences may occur. Poor is known about presentation, treatment, and outcome of iterative recurrences. METHODS: A series of 323 consecutive patients undergoing first LR in the period 2004-2013 was reviewed. Patients with recurrence were included. Any local treatment (surgery, radiofrequency ablation (RFA) and stereotactic body radiation therapy (SBRT)) was analyzed. If first recurrence (1st Rec) was treated, further recurrences and treatments were considered. RESULTS: Overall, 206 (63.8%) patients had 1st Rec; 105 (51.0%) were treated (72 surgery, 19 RFA, 14 SBRT). Among treated patients, 78.1% had 2nd Rec, 74.4% 3rd Rec, 72.2% 4th Rec. Liver involvement progressively decreased (from 81.6 to 30.8%), and pulmonary one increased (from 23.3 to 53.8%). The proportion of treated patients remained stable (1st Rec = 51%, 2nd Rec = 55%, 3rd Rec = 56.3%, 4th Rec = 69.2%): surgery and RFA decreased (from 35.4 to 23.1%; from 9.2 to 0%) and SBRT increased (from 6.8 to 46.2%). Overall, 105 patients received 205 treatments (133 operations in 80 patients). Surgery had the best local disease control: at 2 years 93.4% versus RFA 56.4% (p = 0.0008) and SBRT 74.0% (p = 0.051). In comparison with chemotherapy, recurrence treatment improved survival after 1st Rec (3-year survival 62.9 vs. 13.4%, p < 0.0001), 2nd Rec (61.3 vs. 22.5%, p < 0.0001), and 3rd Rec (2-year survival 88.9 vs. 30.8%, p = 0.005). CONCLUSIONS: Aggressive local treatment of recurrent metastases may improve survival, even in the case of iterative recurrences and extrahepatic lesions. Surgery is the standard, but a multidisciplinary approach should be adopted to enlarge the pool of treatable patients.

Open Liver Resection, Laparoscopic Liver Resection, and Percutaneous Thermal Ablation for Patients with Solitary Small Hepatocellular Carcinoma (≤30 mm): Review of the Literature and Proposal for a Therapeutic Strategy.

BACKGROUND: Patients with a single hepatocellular carcinoma (HCC) ≤3 cm and preserved liver function have the highest likelihood to be cured if treated. The most adequate treatment methods are yet a matter that is debated. METHODS: We reviewed the literature about open anatomic resection (AR), laparoscopic liver resection (LLR), and percutaneous thermal ablation (PTA). RESULTS: PTA is effective as resection for HCC < 2 cm, when they are neither subcapsular nor perivascular. PTA in HCC of 2-3 cm is under evaluation. AR with the removal of the tumor-bearing portal territory is recommended for HCC > 2 cm, except for subcapsular ones. In comparison with open surgery, LRR has better short-term outcomes and non-inferior long-term outcomes. LLR is standardized for superficial limited resections and for left-sided AR. CONCLUSIONS: According to the available evidences, the following therapeutic proposal can be advanced. Laparoscopic limited resection is the standard for any subcapsular HCC. PTA is the first-line treatment for deep-located HCC < 2 cm, except for those in contact with Glissonean pedicles. Laparoscopic AR is the standard for deep-located HCC of 2-3 cm of the left liver, while open AR is the standard for deep-located HCC of 2-3 cm in the right liver. HCC in contact with Glissonean pedicles should be scheduled for resection (open or laparoscopic) independent of their size. Liver transplantation is reserved to otherwise untreatable patients or as a salvage procedure at recurrence.

Emergency Transarterial Embolization in Postoperative Hip Bleeding: Indications, Techniques, and Results in a Retrospective Cohort.

BACKGROUND: The aim of this study is to report the results of transarterial embolization (TAE) in the setting of postoperative bleeding after hip surgery. METHODS: We retrospectively evaluated 40 patients (male:female = 15:25, median age = 68 years) who underwent TAE from 2006 to 2016: 77.5% underwent total hip arthroplasty, 20% open reduction internal fixation, and 2.5% external fixation. Preangiographic multidetector computed tomography angiography was performed in 20 (49%) cases, and 9 of them showed arterial extravasation. Twenty-seven TAEs were performed within a week from surgery; active bleeding was seen in 33 (80.5%) angiograms. Gelatin sponge, microparticles, coils, n-butyl cyanoacrylate, and combinations of them were used as embolic materials. RESULTS: Bleeding was controlled in all cases. The most frequently embolized arteries were branches of the deep femoral artery (n = 17). Permanent embolization agents (microparticles, coils, n-2-butyl-cyanoacrylate) were used in 88% of cases; temporary agents (gelfoam) in 12%. One procedure was complicated by arterial dissection. Hospital discharge averaged 20 days post-TAE (median = 17, range = 3-104). One-month survival rate was 97.5%. One patient died of ischemic bowel perforation. CONCLUSION: TAE is safe and effective in stopping the bleeding of the hip region and should be performed early, to avoid irreversible ischemic damage. Multidetector computed tomography angiography can be used to confirm doubtful evidence of ongoing bleeding. Several embolic materials can be used, each one offering different advantages. Low complication and mortality rates were observed. TAE seems to be the ideal first-line intervention when postoperative bleeding of the operated hip is detected.

Contrast-enhanced MR Imaging versus Contrast-enhanced US: A Comparison in Glioblastoma Surgery by Using Intraoperative Fusion Imaging.

Purpose To compare contrast material enhancement of glioblastoma multiforme (GBM) with intraoperative contrast-enhanced ultrasonography (US) versus that with preoperative gadolinium-enhanced T1-weighted magnetic resonance (MR) imaging by using real-time fusion imaging. Materials and Methods Ten patients with GBM were retrospectively identified by using routinely collected, anonymized data. Navigated contrast-enhanced US was performed after intravenous administration of contrast material before tumor resection. All patients underwent tumor excision with navigated intraoperative US guidance with use of fusion imaging between real-time intraoperative US and preoperative MR imaging. With use of fusion imaging, glioblastoma contrast enhancement at contrast-enhanced US (regarding location, morphologic features, margins, dimensions, and pattern) was compared with that at gadolinium-enhanced T1-weighted MR imaging. Results Fusion imaging for virtual navigation enabled matching of real-time contrast-enhanced US scans to corresponding coplanar preoperative gadolinium-enhanced T1-weighted MR images in all cases, with a positional discrepancy of less than 2 mm. Contrast enhancement of gadolinium-enhanced T1-weighted MR imaging and contrast-enhanced US was superimposable in all cases with regard to location, margins, dimensions, and morphologic features. The qualitative analysis of contrast enhancement pattern demonstrated a similar distribution in contrast-enhanced US and gadolinium-enhanced T1-weighted MR imaging in nine patients: Seven lesions showed peripheral inhomogeneous ring enhancement, and two lesions showed a prevalent nodular pattern. In one patient, the contrast enhancement pattern differed between the two modalities: Contrast-enhanced US showed enhancement of the entire bulk of the tumor, whereas gadolinium-enhanced T1-weighted MR imaging demonstrated peripheral contrast enhancement. Conclusion Glioblastoma contrast enhancement with contrast-enhanced US is superimposable on that provided with preoperative gadolinium-enhanced T1-weighted MR imaging regarding location, margins, morphologic features, and dimensions, with a similar enhancement pattern in most cases. Thus, contrast-enhanced US is of potential use in the surgical management of GBM. © RSNA, 2017 Online supplemental material is available for this article.

Positron Emission Tomography-Computed Tomography for Patients with Recurrent Colorectal Liver Metastases: Impact on Restaging and Treatment Planning.

BACKGROUND: The impact of fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) for patients with colorectal liver metastases (CLM) still is debated. Its relevance could be enhanced in the case of recurrent disease. The current study aimed to elucidate the role of PET-CT in restaging and treatment planning for recurrent CLM. METHODS: A series of 352 consecutive patients undergoing their first liver resection for CLM between 2005 and 2014 was reviewed. Of these patients, 224 (63.6 %) had a recurrence. The 107 patients who had received PET-CT at diagnosis of recurrence before chemotherapy were analyzed. CT was available in all cases, and magnetic resonance imaging (MRI) was available in 64 cases. RESULTS: Extrahepatic lesions were found in 59 patients. Liver and lung recurrences were detected with excellent sensitivity by CT/MRI and PET-CT (liver: 100 vs. 96.7 %; lung: 95.8 vs. 95.8 %). In detecting other recurrence sites, PET-CT had higher sensitivity than CT/MRI (91.5 vs. 54.2 %, p < 0.01; lymph nodes: 93.5 vs. 64.5 %, p = 0.011; peritoneum: 80 vs. 20 %, p = 0.023; bones: 87.5 vs. 37.5 %, nonsignificant difference). For 28.8 % (17/59) of the patients, the diagnosis of extrahepatic disease was obtained thanks to PET-CT (39.5 % considering nonpulmonary lesions). PET-CT modified treatment strategy in 16 (14.9 %) patients, excluding from surgery 15 (20.3 %) of 74 patients resectable at CT/MRI. This latter subgroup had a lower survival rate than the patients resectable after PET-CT (2-year survival, 22.7 vs. 77.8 %; p = 0.004), similar to the patients unresectable at CT/MRI (57.6 %). CONCLUSIONS: In the authors' experience, PET-CT has offered a relevant contribution to restaging of recurrent CLM. It disclosed one fourth of extrahepatic lesions and prevented worthless surgery for about 20 % of patients.

Benign thyroid nodules treatment using percutaneous laser ablation (PLA) and radiofrequency ablation (RFA).

PURPOSE: To evaluate the reduction over time of benign thyroid nodules treated using percutaneous laser ablation (PLA) and radiofrequency ablation (RFA) by the same equipe. MATERIALS AND METHODS: Ninety patients (age 55.6 ± 14.1 years) underwent ablation for benign thyroid nodule causing compression/aesthetic dissatisfaction from 2011. Fifty-nine (age 55.8 ± 14.1 years) underwent RFA and 31 (age 55.2 ± 14.2 years) PLA, ultrasound guided. Technical success, complications, duration of ablation and treatment, energy deployed, volumetric percentage reduction at 1, 6 and 12 months were derived. A regression model for longitudinal measurements was used with random intercept and random slope. Values are expressed as mean ± standard deviation or N (%). RESULTS: Technical success was always obtained. No major complications occurred. Mean ablation time was 30.1 ± 13.8 vs. 13.9 ± 5.9 min (p < .0001) and mean energy deployment was 5422.3 ± 2484.5 J vs. 34 662.7 ± 15 812.3 J in PLA vs. RFA group. Mean volume reduced from 20.3 ± 16.4 ml to 13.17 ± 10.74 ml (42% ± 17% reduction) at 1st month, 8.7 ± 7.4 ml (60% ± 15% reduction) at 6th month and 7.1 ± 7.7 ml (70%% ± 16% reduction) at 12th month, in PLA group, and from 32.7 ± 19.5 ml to 17.2 ± 12.9 ml (51%±15% reduction) at 1st month, 12.8 ± 9.6 ml (64 ± 14% reduction) at 6th month and 9.9 ± 9.2 ml (74% ± 14% reduction) at 12th month in RFA group. No difference in time course of the relative volume reduction between the two techniques was found. CONCLUSIONS: RFA and PLA are similarly feasible, safe and effective in treating benign thyroid nodules when performed by the same equipe. RFA is faster than PLA but require significantly higher energy.

Microwave ablation of primary and secondary liver tumours: ex vivo, in vivo, and clinical characterisation.

PURPOSE: The aim of this study was to compare the performance of a microwave ablation (MWA) apparatus in preclinical and clinical settings. MATERIALS AND METHOD: The same commercial 2.45 GHz MWA apparatus was used throughout this study. In total 108 ablations at powers ranging from 20 to 130 W and lasting from 3 to 30 min were obtained on ex vivo bovine liver; 28 ablations at 60 W, 80 W and 100 W lasting 5 and 10 min were then obtained in an in vivo swine model. Finally, 32 hepatocellular carcinomas (HCCs) and 19 liver metastases in 46 patients were treated percutaneously by administering 60 W for either 5 or 10 min. The treatment outcome was characterised in terms of maximum longitudinal and transversal axis of the induced ablation zone. RESULTS: Ex vivo ablation volumes increased linearly with deposited energy (r2 = 0.97), with higher sphericity obtained at lower power for longer ablation times. Larger ablations were obtained on liver metastases compared to HCCs treated with 60 W for 10 min (p < 0.003), as ablation diameters were 4.1 ± 0.6 cm for metastases and 3.7 ± 0.3 cm for HCC, with an average sphericity index of 0.70 ± 0.04. The results on the in vivo swine model at 60 W were substantially smaller than the ex vivo and clinical results (either populations). No statistically significant difference was observed between ex vivo results at 60 W and HCC results (p > 0.08). CONCLUSIONS: For the selected MW ablation device, ex vivo data on bovine liver was more predictive of the actual clinical performance on liver malignancies than an in vivo porcine model. Equivalent MW treatments yielded a significantly different response for HCC and metastases at higher deposited energy, suggesting that outcomes are not only device-specific but must also be characterised on a tissue-by-tissue basis.

Non-healing post-surgical fistulae: treatment with image-guided percutaneous injection of cyanoacrylic glue.

OBJECTIVES: To present the results of our experience with cyanoacrylic glue percutaneous injection to treat post-surgical non-healing enteric fistulae after failure of standard treatments. METHODS: Eighteen patients (14 males; age range 33-84, mean 69 years) were treated for a non-healing post-surgical enteric fistula after failure of standard treatments. Under computed tomography and/or fluoroscopic guidance, a mixture of cyanoacrylic glue (Glubran 2, GEM, Viareggio, Italy) and ethiodized oil was injected at the site of the fistula. Fistula was considered healed when no material was drained by the percutaneous drainage and a subsequent computed tomography confirmed the disappearance of any fluid collection. RESULTS: In all cases, it was possible to reach the site of the fistula using a percutaneous access. A median of 1 injection (range 1-5) was performed. Fistula healing was achieved in 16/18 (89 %) patients. One patient died for other reasons before fistula healing. Median time for fistula healing was 0 days (mean 8, range 0-58 days). No complications occurred. Reoperation was needed in one patient. CONCLUSIONS: Percutaneous injection of cyanoacrylic glue is feasible, safe, and effective to treat non-healing post-surgical enteric fistulae. It may represent a further option to avoid surgical reoperation in frail patients.

Identification of residual tumor with intraoperative contrast-enhanced ultrasound during glioblastoma resection.

OBJECTIVE: The purpose of this study was to assess the capability of contrast-enhanced ultrasound (CEUS) to identify residual tumor mass during glioblastoma multiforme (GBM) surgery, to increase the extent of resection. METHODS: The authors prospectively evaluated 10 patients who underwent surgery for GBM removal with navigated ultrasound guidance. Navigated B-mode and CEUS were performed prior to resection, during resection, and after complete tumor resection. Areas suspected for residual tumors on B-mode and CEUS studies were localized within the surgical field with navigated ultrasound and samples were sent separately for histopathological analysis to confirm tumor presence. RESULTS: In all cases tumor remnants were visualized as hyperechoic areas on B-mode, highlighted as CEUS-positive areas, and confirmed as tumoral areas on histopathological analysis. In 1 case only, CEUS partially failed to demonstrate residual tumor because the residual hyperechoic area was devascularized prior to ultrasound contrast agent injection. In all cases CEUS enhanced B-mode findings. CONCLUSIONS: As has already been shown in other neoplastic lesions in other organs, CEUS is extremely specific in the identification of residual tumor. The ability of CEUS to distinguish between tumor and artifacts or normal brain on B-mode is based on its capacity to show the vascularization degree and not the echogenicity of the tissues. Therefore, CEUS can play a decisive role in the process of maximizing GBM resection.