The PEARL Approach for CT-guided Lung Biopsy: Assessment of Complication Rate.

Background Percutaneous CT-guided biopsy of lung nodules is an established method with high diagnostic accuracy but a high rate of pneumothorax and chest tube insertion compared with endobronchial methods. Purpose To investigate the effect of a protocol combining patient positioning biopsy-side down, needle removal during expiration, autologous blood patch sealing, rapid rollover, and pleural patching (PEARL) on complication rate after percutaneous CT-guided lung biopsy, especially chest tube insertion. Materials and Methods In a secondary analysis of both prospectively and retrospectively acquired data from December 2019 to November 2020, consecutive participants underwent biopsy with use of the PEARL protocol (prospective data) and were compared with patients who underwent biopsy at the same tertiary cancer center according to the standard method without any additional techniques (controls, retrospective data). Patient demographics, lesion characteristics, intraprocedural data, complications, and histologic results were recorded and compared. Results One hundred patients in the control group (mean age ± standard deviation, 63 years ± 12; 61 men) and 100 participants in the PEARL group (mean age, 64 years ± 12; 48 men) were evaluated. No differences were found in patient and lesion characteristics. The emphysema rate was 47 of 100 patients (47%) in both groups. The rate of pneumothorax was 37 of 100 patients (37%) in the control group versus 16 of 100 (16%) in the PEARL group (P = .001). Of the pneumothoraxes that occurred, fewer were during the intervention in the PEARL group, with 21 of 37 onsets (57%) in the control group versus three of 16 onsets (19%) in the PEARL group (P < .001). A chest tube was inserted in 13 of 100 patients (13%) in the control group and only in one of 100 (1%) in the PEARL group (P = .002). Histologic findings were diagnostic in 94 of 100 patients (94%) in the control group and 95 of 100 (95%) in the PEARL group (P > .99). Conclusion During CT-guided percutaneous lung biopsy, a protocol of positioning biopsy-side down, needle removal during expiration, autologous blood patch sealing, rapid rollover, and pleural patching, or PEARL, reduced rates of pneumothorax and chest tube insertion. © RSNA, 2021.

Combined local treatments for vertebral metastases with limited epidural extension.

OBJECTIVES: Vertebral metastases with limited epidural extension (VMLEE) are frequently encountered in cancer patients; they can cause severe and debilitating symptoms including pain and neurological impairment and are usually treated by radiotherapy. In this study, we mainly evaluated the safety of combined local treatments (CLT), associating radiofrequency ablation (RFA) with vertebroplasty and radiotherapy (RT) to treat VMLEE. Also, we aimed to evaluate the short-term efficacy of CLT on bone metastases palliation and long-term prevention of skeletal-related events. METHODS: We retrospectively reviewed treatment complications, pain palliation, and skeletal complications after combined local treatments (CLT) for vertebral metastasis with limited epidural extension (VMLEE). RESULTS: Eighteen consecutive patients had CLT for 24 VMLEE, between June 2016 and January 2021. No major post-treatment complication was recorded. Nine patients had pain before the initiation of CLT. One month after CLT, only 3 patients had residual pain with a significant decrease of visual analogue scale (VAS), from 7.3 ± 2.4 to 2 ± 0 (p = .008), as well as the mean morphine milligram equivalent dose from 196.6 ± 135.7 to 38.5 ± 26, p = .008. Mean follow-up was 16.7 ± 11.5 months. Only one vertebra showed an increase of a preexisting vertebral fracture. Nine VMLEE had evidence of residual disease, including 2 which resulted in spinal cord compression (2, 11 months). CONCLUSION: CLT was safe and effective for pain palliation and long-term prevention of skeletal-related events for treatment of patients with VMLEE. The effectiveness of this combined treatment on tumor control and epidural involvement on the long term needs further investigation.

Thermal ablation in the management of oligometastatic colorectal cancer.

PURPOSE: To review available evidence on thermal ablation of oligometastatic colorectal cancer. METHODS: Technical and cancer specific considerations for percutaneous image-guided thermal ablation of oligometastatic colorectal metastases in the liver and lung were reviewed. Ablation outcomes are compared to surgical and radiation therapy literature. RESULTS: The application of thermal ablation varies widely based on tumor burden, technical expertise, and local cancer triage algorithms. Ablation can be performed in combination or in lieu of other cancer treatments. For surgically non-resectable liver metastases, a randomized trial has demonstrated the superiority of thermal ablation combined with chemotherapy compared to systemic chemotherapy alone in term of progression-free survival and overall survival (OS), with 5-, and 8-year OS of 43.1% and 35.9% in the combined arm vs. 30.3% and 8.9% in the chemotherapy alone arm. As ablation techniques and technology improve, the role of percutaneous thermal ablation may expand even into surgically resectable disease. Many of the prognostic factors for better OS after local treatment of lung metastases are the same for surgery and thermal ablation, including size and number of metastases, disease-free interval, complete resection/ablation, negative carcinoembryonic antigen, neoadjuvant chemotherapy, and controlled extra-pulmonary metastases. When matched for these factors, thermal ablation for lung and liver metastases appears to provide equivalent overall survival as surgery, in the range of 50% at 5 years. Thermal ablation has limitations that should be respected to optimize patient outcomes and minimize complications including targets that are well-visualized by image guidance, measure <3cm in diameter, and be located at least 3mm distance from prominent vasculature or major bronchi. CONCLUSIONS: The routine incorporation of image-guided thermal ablation into the therapeutic armamentarium for the treatment of oligometastatic colorectal cancer can provide long survival and even cure.

Risk factors for local tumor progression after RFA of pulmonary metastases: a matched case-control study.

OBJECTIVES: Curative treatment of oligometastatic pulmonary disease aims at eradication of all metastases. Radiofrequency ablation (RFA) has been shown to be an efficient method and the frequency of local tumor progression (LTP) should be minimized. The objective of this study was to determine the morphological and treatment-related risk factors for LTP after RFA of pulmonary metastases. MATERIALS AND METHODS: All patients treated with RFA for pulmonary metastases from 2002 to 2014 were reviewed. All LTPs from 2011 to 2014 were individually matched on the basis of tumor size, number, and histology. In total, 48 LTPs and 112 controls were blindly analyzed for morphological factors including vicinity of bronchus and vessels as well as treatment-related factors such as the size of the ablation zone and ablation margins. RESULTS: In the simple regression analysis, the significant predictive variables were ≤ 5-mm distance to a large bronchus (OR = 4.94; p = 0.0095) or large vessel (OR = 7.09; p < 0.001), minimal ablation margin (≤ 5 mm (OR = 42.67; p < 0.001), and a central-peripheral ablation offset/ablation zone size > 0.36 (OR = 13.83; p = 0.013). In the multiple regression model, only a minimal ablation margin ≤ 5 mm remained a significant risk factor for LTP. CONCLUSION: Only the minimal ablation margin remains significant in the multiple regression analysis; the other factors are presumably surrogates of an insufficient ablation margin. Improvement of lung RFA outcomes can probably be obtained by immediate post RFA evaluation of ablation margins to ensure a minimal ablation margin of at least 5 mm. KEY POINTS: • A distance < 5 mm to a bronchus or vessel of over 3 mm diameter is associated with insufficient ablation margin and thus risk factors for local tumor progression after pulmonary radiofrequency ablation. • A minimal ablation margin of > 5 mm after pulmonary RFA is associated with significantly less local tumor progression and should be looked for at the end of treatment session before needle removal in order to decrease local tumor progression. • Tumor location, pleural contact, occurrence of intra-alveolar hemorrhage, pulmonary atelectasis, and pneumothorax are not associated with an increased risk of local tumor progression.

Image-guided Percutaneous Fixation with Internal Cemented Screws of Impending Femoral Neck Pathologic Fractures in Patients with Metastatic Cancer: Safety, Efficacy, and Durability.

Background Prophylactic image-guided procedures performed by interventional radiologists for impending pathologic fractures are becoming more pertinent, as patients with metastatic cancer have extended overall survival because of advanced therapies. Purpose To evaluate the efficacy, safety, and palliative durability of collimated-beam CT-guided percutaneous fixation with internal cemented screws (FICS) for impending pathologic fractures of the femoral neck. Materials and Methods This single-institute retrospective study examined all patients with metastatic cancer treated between February 2010 and October 2019 with collimated-beam CT-guided percutaneous FICS procedures for preventive consolidation of impending femoral neck pathologic fractures. The short-term palliative efficacy was assessed through comparison of visual analog scale (VAS) scores before and 1 month after FICS. A review of cross-section imaging and clinic reports identified any procedural complications. Long-term consolidation efficacy was defined as the absence of any screw dislodgement or development of a pathologic fracture at completion of the study. The Wilcoxon test was used for the mean comparison of paired nonparametric variables. Results Sixty-one consecutive patients (mean age, 59 years ± 11 [standard deviation]; 35 women) underwent preventive FICS for consolidation of impending pathologic femoral neck fracture with a mean follow-up of 533 days ± 689. Two patients died of cancer within the first month. Complications were limited to three self-resolving hematomas. The mean VAS score decreased 1 month after FICS from 4.2 ± 3.2 to 1.8 ± 2.0 (P < .001). The long-term consolidation efficacy was 92% (54 of 59 patients), with three of 59 patients (5%) subsequently developing fractures despite FICS and an additional two of 59 patients (3%) with durable FICS undergoing definitive total hip arthroplasty surgery because of local tumor progression. Conclusion Percutaneous fixation with internal cemented screws as performed by the interventional radiologist is a safe nonsurgical treatment that provides an effective palliative result and durable prevention for impending pathologic fractures of the femoral neck. © RSNA, 2020 Online supplemental material is available for this article.

Safety and Efficacy of Multilevel Thoracolumbar Vertebroplasty in the Simultaneous Treatment of Six or More Pathologic Compression Fractures.

PURPOSE: To assess the safety and efficacy of multilevel thoracolumbar vertebroplasty in the simultaneous treatment of ≥ 6 painful pathologic compression fractures. MATERIALS AND METHODS: Retrospective review was conducted of 50 consecutive patients treated with vertebroplasty for ≥ 6 pathologic compression fractures in a single session for pain palliation at a tertiary single cancer center from 2015 to 2019. Outcomes measured included procedural safety according to Common Terminology Criteria for Adverse Events (CTCAE), change in 4-week postprocedure back pain by numeric rating scale (NRS), comparison of daily opioid medication consumption, and development of skeletal-related events. RESULTS: A total of 397 pathologic compression fractures were treated during 50 sessions (mean, 7.9 per patient ± 1.5). Mean procedure duration was 162 minutes ± 35, mean postoperative hospitalization duration was 1.6 days ± 0.9, and mean follow-up duration was 401 days ± 297. Seven complications were recorded, including 1 case of symptomatic polymethyl methacrylate pulmonary embolism. No major complications (CTCAE grade 4/5) were reported. NRS pain score was significantly decreased (5.0 ± 1.8 vs 1.7 ± 1.4; P < .0001), with a mean score decrease of 3.3 points (66%). Opioid agent use decreased significantly (76 mg/24 h ± 42 vs 45 mg/24 h ± 37; P = .0003), with a mean decrease of 30 mg/24 h (39%). Skeletal-related events occurred in 7 patients (14%). CONCLUSIONS: Multilevel vertebroplasty for ≥ 6 pathologic compression fractures is safe and provides significant palliative benefit when performed simultaneously.

Lung microwave ablation - an in vivo swine tumor model experiment to evaluate ablation zones.

PURPOSE: To evaluate microwave ablation (MWA) algorithms, comparing pulsed and continuous mode in an in vivo lung tumor mimic model. MATERIALS AND METHODS: A total of 43 lung tumor-mimic models of 1, 2 or 3 cm were created in 11 pigs through an intra-pulmonary injection of contrast-enriched minced muscle. Tumors were ablated under fluoroscopic and 3D-CBCT-guidance using a single microwave antenna. Continuous (CM) and pulsed mode (PM) were used. According to tumor size, 3 different algorithms for both continuous and pulsed mode were used. The ablation zones were measured using post-procedural 3D-CBCT and on pathologic specimens. RESULTS: Two radiologists measured the ablation zones on CBCT and they significantly correlated with macroscopic and microscopic pathological findings: r = 0.75 and 0.74 respectively (p < 0.0001) (inter-observer correlation r = 0.9). For 1, 2 and 3 cm tumors mimics lesions (TMLs), mean maximal and transverse ablation diameters were 3.6 [Formula: see text] 0.3 × 2.2 [Formula: see text] 0.3 cm; 4.1 [Formula: see text] 0.5 × 2.6 [Formula: see text] 0.3 cm and 4.8 [Formula: see text] 0.3 × 3.2 [Formula: see text] 0.3 cm respectively using CM; And, 3.0 [Formula: see text] 0.2 × 2.1 [Formula: see text] 0.2 cm; 4.0 [Formula: see text] 0.4 × 2.7 [Formula: see text] 0.4 cm and 4.6 [Formula: see text] 0.4 × 3.2 [Formula: see text] 0.4 cm respectively for PM, without any significant difference except for 1 cm TMLs treated by PM ablation which were significantly smaller (p = 0.009) The sphericity index was 1.6, 1.6, 1.5 and 1.4, 1.5, 1.4 at 1, 2 and 3 cm for CM and PM respectively, p = 0.07, 0.14 and 0.13 for 1, 2 and 3 cm tumors mimics. CONCLUSION: Microwave ablation for 1-3 cm lung tumors were successfully realized but with a moderate reproducibility rate, using either CM or PM. Immediate post ablation CBCT can accurately evaluate ablation zones.

Thermal ablation of ultrasound and non-contrast computed tomography invisible primary and secondary liver tumors: targeting by selective intra-arterial lipiodol injection.

PURPOSE: To evaluate the technical feasibility and outcomes of thermal ablation following selective intra-arterial lipiodol injection (SIALI) for targeting primary and secondary liver tumors invisible on ultrasound (US) and non-contrast computed tomography (CT). METHODS: This retrospective study included 18 patients with 20 tumors (67% male, mean age 60.8 ± 12.1 years). The 20 tumors included 15 liver metastases and 5 hepatocellular carcinomas. All patients underwent single-session SIALI and subsequent CT-guided thermal ablation. The primary outcome was a technical success, defined as visualization of the tumor after SIALI and successful thermal ablation. Secondary outcomes were local recurrence rate and procedure-related complications. RESULTS: The median tumor size was 1.5 (1-2.5) cm. In addition, SIALI was performed with a median volume of 3 (1-10) mL of lipiodol resulting in intra-tumoral iodized oil accumulation in 19 tumors and negative imprint with iodized oil accumulation of the surrounding liver parenchyma in 1 tumor. The technical success rate was 100%. No local occurrence was observed at a mean follow-up time of 3 ± 2.5 years. CONCLUSION: SIALI to tag liver tumors not visible with US and non-contrast CT before percutaneous ablation is highly feasible and has a high success rate for the treatment of both primary and secondary liver tumors.

Coil Embolization of Variant Hepatic Arteries During Percutaneous Arterial Port Catheter Placement for Intraarterial Chemotherapy: Analysis of Intrahepatic Perfusion Redistribution and Treatment Efficacy.

PURPOSE: The purpose of this study was to analyze the intrahepatic perfusion redistribution after embolization of hepatic arterial variants during percutaneous arterial port catheter placement as well as to investigate the treatment efficacy of intraarterial chemotherapy in perfusion redistribution-dependent compared to redistribution-independent liver areas. MATERIALS AND METHODS: This retrospective study included 62 patients (67.7% males, mean age of 56 ± 12 years). A replaced left hepatic artery was encountered in 36/62 (58.1%), a replaced right hepatic artery in 19/62 (30.6%) and a replaced left and right hepatic artery in 7/62 of patients (11.3%), respectively. Subjective perfusion analysis was performed on digital subtracted angiography and computed tomography (CT)/cone-beam computed tomography (CBCT) images evaluating the visibility of the main, segmental and subsegmental branches of the embolized variant hepatic artery, re-perfused from intrahepatic arterial anastomoses. For objective perfusion analysis ROI measurements on CT/CBCT images were taken in the redistribution-dependent and redistribution-independent liver lobe. Response analysis according to RECIST 1.1 was separately calculated for the redistribution-dependent and redistribution-independent liver lobe. RESULTS: Intrahepatic reperfusion of the embolized variant hepatic artery was observed immediately after embolization with visualization of the subsegmental branches in 95.2% of patients. ROI measurements on CT/CBCT images (right lobe mean 76 ± 30.2 HU, left lobe mean 74.4 ± 30.5, p-value 0.88) did not show any differences. Treatment response after intraarterial chemotherapy did not differ between the redistribution-dependent and redistribution-independent liver lobes. CONCLUSION: Embolization of hepatic arterial variants during percutaneous arterial port catheter placement results in effective intrahepatic perfusion redistribution and does not compromise treatment efficacy of intraarterial chemotherapy in the redistribution-dependent liver lobe.

Robotic assistance for percutaneous needle insertion in the kidney: preclinical proof on a swine animal model.

BACKGROUND: We evaluated the accuracy, safety, and feasibility of a computed tomography (CT)-guided robotic assistance system for percutaneous needle placement in the kidney. METHODS: Fiducials surgically implanted into the kidneys of two pigs were used as targets for subsequent robotically-assisted needle insertion. Robotically-assisted needle insertions and CT acquisitions were coordinated using respiratory monitoring. An initial scan volume data set was used for needle insertion planning defining skin entry and target point. Then, needle insertion was performed according to robot positioning. The accuracy of needle placement was evaluated upon the distance between the needle tip and the predefined target on a post needle insertion scan. A delayed contrast-enhanced CT scan was acquired to assess safety. RESULTS: Eight needle trajectories were performed with a median procedural time measured from turning on the robotic system to post needle insertion CT scan of 21 min (interquartile range 15.5-26.5 min). Blind review of needle placement accuracy was 2.3 ± 1.2 mm (mean ± standard deviation) in lateral deviation, 0.7 ± 1.7 mm in depth deviation, and 2.8 ± 1.3 mm in three-dimensional Euclidian deviation. All needles were inserted on the first attempt, which determined 100% feasibility, without needle readjustment. The angulation and length of the trajectory did not impact on the needle placement accuracy. Two minor procedure-related complications were encountered: 2 subcapsular haematomas (13 × 6 mm and 35 × 6 mm) in the same animal. CONCLUSIONS: Robotically-assisted needle insertion was shown feasible, safe and accurate in a swine kidney model. Further larger studies are needed.

Thermal Ablation Combined with Selective Transarterial Embolization of Centrally Located Renal Cell Carcinomas Measuring 3 cm or Larger.

PURPOSE: The purpose of this study was to evaluate the long-term outcomes of patients with centrally located renal cell carcinomas (RCC) measuring 3 cm or larger, treated by a standardized transarterial embolization protocol associated with percutaneous ablation. MATERIALS AND METHODS: This retrospective study included 11 patients (73% male, mean age 73.4 ± 6.5 years) with RCC and contraindications for surgery. All patients underwent a single session combining transarterial embolization with iodized oil and subsequent thermal percutaneous ablation. Primary and secondary local tumor control were analyzed, defined as absence of any contrast enhancing nodular lesion in the treated area after a single or percutaneous re-treatment session, respectively. RESULTS: Mean tumor size was 3.5 ± 0.3 cm (range 3-4 cm) with a mean R.E.N.A.L. nephrometry score ((R)adius; (E)xophytic, endophytic properties; (N)earness to the collecting system; (A)nterior, posterior; (L)ocation relative to the polar line) of 8 ± 0.9 (range 7-9). Nearness to the collecting system was 4-7 mm in two patients (18%) and ≤ 4 mm in nine patients (82%). After a mean follow-up of 5.2 ± 2.5 years primary and secondary local tumor control rate were 82% and 100%, respectively. No change in serum creatinine levels and glomerular filtration rate was observed compared to pre-treatment values. CONCLUSION: A combined treatment of selective transarterial embolization and percutaneous ablation of large centrally located RCC (> 3 cm) is safe, feasible and can achieve excellent oncological long-term results. Larger prospective studies are needed.

Single-session transarterial chemoembolization combined with percutaneous thermal ablation in liver metastases 3 cm or larger.

PURPOSE: The purpose of this study was to evaluate the safety and efficacy of transarterial chemoembolization (TACE) combined with percutaneous thermal ablation in patients with liver metastases 3 cm in diameter or larger. MATERIALS AND METHODS: This retrospective study included 39 patients with a total of 46 liver metastases treated. There were 14 men and 25 women, with a mean age of 55 ± 13.3 (SD) (age range: 28-77 years). All patients were treated with a combination of TACE and thermal ablation in a single session. Primary outcome was local tumor progression. Secondary outcomes were procedure related complications and systemic disease progression. RESULTS: Mean tumor size was 3.6 ± 0.6 (SD) cm (range: 3-5 cm). Conventional TACE was performed in 32 liver metastases (32/46; 70%) and drug-eluting beads-TACE in 14 liver metastases (14/46; 30%) followed by radiofrequency ablation in 34 (34/46; 74%), microwave ablation in 11 (11/46; 24%) and cryoablation in one (1/46; 2%) metastasis. Four grade 2 (4/39; 10%) complications were observed. After a mean follow up of 31.9 ± 26.1 (SD) months (range: 2-113 months) overall local tumor progression rate was 15% (7/46). Local tumor progression rate at 12 months was 13% (6/46). Overall systemic disease progression was seen in 29 patients (29/39; 74%) with a systemic disease progression rate at 12 months of 59% (23/39). CONCLUSION: Treatment of large liver metastases with TACE and thermal ablation in a single session is safe and achieves high local control rate.

Percutaneous Fixation of Impending Fracture of the Hip.

According to the literature, prophylactic consolidation of proximal femur lytic metastasis the is recommended when the Mirels' score is above 8. Osteoplasty (cementoplasty of proximal femur) alone provides inadequate consolidation. Various mini-invasive technics, augmented osteoplasties, have been proposed for better long-term consolidation. The aim of this review is to detail the augmented osteoplasty techniques described in the literature and to report their safeties and efficacies to prevent pathological fracture of the proximal femur. A PubMed research found 8 studies that evaluated augmented osteoplasty of the proximal femur in cancer patients. All devices demonstrate adequate safety and low rate of secondary pathological fractures.

Loco-Regional Therapies in Oligometastatic Adrenocortical Carcinoma.

Objective: The recommended first-line treatment for low-tumor-burden ACC (stage IVa ACC) not amenable to radical resection is mitotane in association with loco-regional treatments (LRs). The aim of this study was to determine the patient population that would benefit the most from LR. Materials and methods: This retrospective monocentric expert center chart review study was performed from 2008 to 2021 and included stage IVa patients (≤2 tumoral organs) treated with LR (either radiotherapy, surgery, or interventional radiology). The primary endpoint was disease control (DC). Correlations between DC, time to systemic chemotherapy (TTC), overall survival (OS), and tumor characteristics were analyzed using Kaplan−Meier survival analysis and Cox's proportional hazards regression model for multivariate analysis. Results: Thirty-four women (57%) and 26 men with a median age of 48.1 years (IQR: 38.3−59.8) were included. One hundred and nine LRs were performed, with a median of 2 (IQR: 1−3) per patient. DC was achieved in 40 out of 60 patients (66.7%). Patients with DC had a significantly longer TTC (HR: 0.27, p < 0.001) and OS (HR: 0.22, p < 0.001). Patients with less than or equal to 5 metastases (HR: 6.15 (95% CI: 1.88−20.0), p = 0.002) or a maximum metastasis diameter below 3 cm had higher rates of DC (HR: 3.78 (95% CI: 1.09−13.14), p = 0.035). Conclusion: stage IVa ACC patients with ≤5 metastases or a maximum metastasis diameter below 3 cm had favorable responses to LR. We propose the name oligometastatic ACC for this subgroup of patients.

Feasibility, safety and efficacy of human intra-tumoral immuno-therapy. Gustave Roussy's initial experience with its first 100 patients.

PURPOSE: Many intratumoural (IT) immunotherapies are currently developed in the clinic with the aim of overcoming primary and secondary resistance and/or to limit on-target/off-tumour toxicities of immune checkpoint targeted therapies. This study aimed to describe the feasibility, safety and efficacy of IT immunotherapy treatments. DESIGN: This retrospective single-centre study included the first 100 consecutive patients enrolled in Gustave Roussy's Human IntraTumoral-ImmunoTherapy (HIT-IT) program. Patient characteristics, target description, image guidance, safety and response according to iRECIST (Response Evaluation Criteria in Solid Tumours for immunotherapy trials) were recorded. Predictive factors of complications and responses were analysed. Survival was also reported. RESULTS: From 09/2015 to 05/2020, 100 patients had 115 tumours injected during 423 treatment cycles. Most frequent primary tumour arose from the skin (n = 49), digestive track (n = 4) or head and neck (n = 8). Injected tumours' mean diameter was 37 ± 23 mm, and a median number of 4 IT injections per patient (interquartile range:3-5) were performed. Targeted tumours for IT injections were superficial lymph nodes (36.5%), subcutaneous lesions (25.2%), liver tumours (20.9%) and others (17.4% including tumour sites such as deep lymph nodes or lung). Most patients (72%) received systemic immunotherapy in combination with HIT-IT. Procedure- and drug-related adverse events (AEs) occurred in 11.3% and 33.3% of the treatment cycles, respectively. Only 3 procedure-related AEs were grade-3 (0.7%); and no grade-4 or 5 occurred. Among all cycles, 7 grade-3 and 1 grade-5 drug-related AEs were reported. Complete and partial responses were achieved for 5% and 18% of patients, respectively, while stable disease was the best response for 11%. Patients receiving HIT-IT as a 1st-line treatment (24%), or not previously pre-treated with immunotherapy (53%) responded better, p = 0.001 and p = 0.004, respectively. From 1st cycle of IT, 12-month overall progression-free survival and overall survival were 21% (14-31%) and 57% (47-68%), respectively. CONCLUSIONS: This retrospective study, conducted on patients with cancer and treated within clinical trials at Gustave Roussy, demonstrates the feasibility and safety of the IT immunotherapy strategy.

Role of Thermal Ablation in Colorectal Cancer Lung Metastases.

Background: Consensus guidelines of the European Society for Medical Oncology (ESMO) (2016) provided recommendations for the management of lung metastases. Thermal ablation appears as a tool in the management of these secondary pulmonary lesions, in the same manner as surgical resection or stereotactic ablative radiotherapy (SABR). Methods: Indications, technical considerations, oncological outcomes such as survival (OS) or local control (LC), prognostic factors and complications of thermal ablation in colorectal cancer lung metastases were reviewed and put into perspective with results of surgery and SABR. Results: LC rates varied from 62 to 91%, with size of the metastasis (<2 cm), proximity to the bronchi or vessels, and size of ablation margins (>5 mm) as predictive factors of LC. Median OS varied between 33 and 68 months. Pulmonary free disease interval <12 months, positive carcinoembryonic antigen, absence of neoadjuvant chemotherapy and uncontrolled extra-pulmonary metastases were poor prognostic factors for OS. While chest drainage for less than 48 h was required in 13 to 47% of treatments, major complications were rare. Conclusions: Thermal ablation of a selected subpopulation of patients with colorectal cancer lung metastases is safe and can provide excellent LC and delay systemic chemotherapy.

Prophylactic Percutaneous Consolidation of Large Osteolytic Tumors of the Pelvic Ring Using Fixation by Internal Cemented Screws.

Purpose To evaluate the efficacy, durability, and safety of percutaneous fixation by internal cemented screw (FICS) for prophylactic consolidation of impending pathologic fractures of the pelvic ring. Materials and Methods In this single-institute retrospective study, patients with large, minimally symptomatic to asymptomatic osteolytic tumors of the pelvic ring that were treated with percutaneous cone-beam CT-guided FICS procedures were included (January 2014 to May 2019). Follow-up cross-section imaging and clinical reports were reviewed for procedural complications and assessment of the long-term consolidation efficacy on the basis of the development of pathologic fracture or need for additional surgical intervention. All continuous variables were expressed as a mean with standard deviation, and dichotomous variables were expressed as frequencies and percentages. Results Fifty consecutive patients (mean age, 60 years ± 12; 27 men) underwent prophylactic FICS for consolidation of 54 osteolytic tumors (mean size, 51 mm ± 21.5; range, 30-114 mm). Local tumor destruction was performed in association with FICS in 38 patients (76%) using percutaneous thermal and/or radiation therapy. Follow-up exceeded a year in 35 patients (70%), with mean follow-up of 22 months ± 18 (range, 1-67 months). Long-term consolidation efficacy was 98% (49 of 50), with the development of a pathologic fracture in only one patient 20 months after FICS. Procedural complications were limited to two patients with self-resolving hematoma, one patient with inflammatory sciatic pain, and one patient with focal pain at the ischial tuberosity. Conclusion Percutaneous FICS provides a safe and durable minimally invasive treatment for the prevention of pathologic fractures of the pelvic ring. Keywords: Interventional-MSK, Percutaneous, Skeletal-Axial, Metastases, Oncology Supplemental material is available for this article. © RSNA, 2020.

Interventional Radiology for Local Immunotherapy in Oncology.

Human intratumoral immunotherapy (HIT-IT) is under rapid development, with promising preliminary results and high expectations for current phase III trials. While outcomes remain paramount for patients and the referring oncologists, the technical aspects of drug injection are critical to the interventional radiologist to ensure optimal and reproducible outcomes. The technical considerations for HIT-IT affect the safety, efficacy, and further development of this treatment option. Image-guided access to the tumor allows the therapeutic index of a treatment to be enhanced by increasing the intratumoral drug concentration while minimizing its systemic exposure and associated on-target off-tumor adverse events. Direct access to the tumor also enables the acquisition of cancer tissue for sequential sampling to better understand the pharmacodynamics of the injected immunotherapy and its efficacy through correlation of immune responses, pathologic responses, and imaging tumor response. The aim of this article is to share the technical insights of HIT-IT, with particular consideration for patient selection, lesion assessment, image guidance, and technical injection options. In addition, the organization of a standard patient workflow is discussed, so as to optimize HIT-IT outcome and the patient experience.

Lung Ablation - How I Do It.

Interventional oncology and the value of thermal ablation of small tumors is increasingly recognized by the oncological community. Primary lung cancers and lung metastases have been one of the most researched applications of percutaneous ablation and as interventional oncologists gain more experience and confidence, it is becoming a more effective treatment with expanding indications. Importantly, the current literature does not demonstrate major differences in survival between ablation, sublobar resection, and stereotactic body radiation. The advantages of percutaneous ablation over other local therapies like surgery or SBRT are significantly lower morbidity, mortality, and repeatability of treatments. The focus of this essay is to highlight technical and procedural aspects of lung ablation as well as management and follow-up in a practical fashion.

Multi-Level Vertebroplasty for 6 or More Painful Osteoporotic Vertebral Body Compression Fractures Performed in the Same Procedural Setting: A Safety and Efficacy Report in Cancer Patients.

PURPOSE: To assess safety and efficacy of multi-level vertebroplasty, when treating 6 or more levels in the same procedural setting for the management of osteoporotic vertebral compression fractures (oVCF) in cancer patients. MATERIALS AND METHODS: Single institution retrospective review from 2015 to 2019 of patients treated for multi-level oVCF in a single session procedural setting by vertebroplasty of 6 or more levels. Procedure outcomes collected included procedural complications, pre- and 4 week post-procedure pain score by numeric rating scale, opioid usage, and vertebral height changes. RESULTS: In total, 197 vertebral levels were treated in 24 procedures (mean 8.2 ± 1.8 levels). Mean procedure duration was 167 + / - 41 min, and mean postoperative hospitalization duration was 2.1 + / - 1.9 days. Four grade I or II complications occurred according to CIRSE classification. Two patients had a symptomatic pulmonary cement embolism; although there was no statistical difference between pre- and postoperative mean blood saturation (95.9 + / - 1.7% and 94.8 + / - 2.0%, respectively, p = 0.066). Pain score significantly improved after treatment (6.5 ± 1.3 vs 3.2 + / - 1.4, p < 0.0001) with a mean decrease of 3.3 (51%). Post-procedure daily opioid use also significantly improved (mean 35.8 + / - 36.8 mg/24 h vs 18.5 + / - 27.8 mg/24 h, p = 0.0089), with a mean decrease of 17.3 mg/24 h (48%). Refracture was found in 2 of 105 levels treated (1.9%), and no difference was found in thoraco-lumbar height and angulation. Five patients experienced new painful fractures at a non-treated level. CONCLUSION: Multi-level vertebroplasty for 6 or more levels is a safe and effective treatment for the management of multi-level oVCF in cancer patients.