Prospective Series of Transarterial Chemoembolization of Metastatic Colorectal Cancer to the Liver with 30-60 µm Microspheres Loaded with Irinotecan.

PURPOSE: To describe safety and clinical outcomes among patients with metastatic colorectal cancer (mCRC) to the liver treated with transarterial chemoembolization with HepaSphere™ Microspheres 30-60 µm loaded with irinotecan (ΙRI-HEP-TACE). MATERIAL AND METHODS: In this prospective study (NCT04866290), 100 adults with confirmed mCRC to the liver who were ineligible for resection were enrolled and followed up to 24 months or death. Study outcomes among Salvage (patients not tolerating more cycles of chemotherapy) and Non-salvage patients included overall survival (OS), progression-free survival (PFS), objective response (OR), objective response rate (ORR), best tumor response (BTR), adverse events (AEs), and pharmacokinetics of irinotecan and its active metabolite, 7-ethyl-10-hydroxy-camptothecin (SN38). RESULTS: The median age was 66 years (range: 31-89). Median OS was 15.08 months (95% confidence interval [CI]: 12.33-17.25). PFS was 8.52 months (95% CI: 6.0-9.0; p < 0.001). ORR was 42.2% (95% CI: 31.57-53.50) and 35.9% (95% CI: 25.57-47.62) based on modified RECIST (Response Evaluation Criteria in Solid Tumors) and RECIST 1.1 criteria. BTR was not significantly different between mRECIST and RECIST (p = 0.745). The Non-salvage group had a statistically significant difference in median OS relative to the Salvage group (15.3 vs. 3 months; p < 0.001). Pharmacokinetic analyses demonstrated no correlation of OS with plasma concentration of irinotecan and SN38 (all p > 0.05). Most AEs were Grade 2 (257/279), the most common AE was right upper abdominal pain (180/279). One major AE (tumor rupture) was reported. CONCLUSION: IRI-HEP-TACE is an alternative treatment for patients with Non-salvage mCRC to the liver.

Safety, Efficacy and Distribution of Doxorubicin Loaded Radiopaque Beads in Chemoembolization in Intermediate Stage Hepatocellular Carcinoma (HCC) with Correlation with Local Response.

PURPOSE: The primary objectives of this study were to evaluate safety, and efficacy of Transarterial Chemoembolization (TACE) using doxorubicin-loaded radiopaque microspheres (DC Bead LUMI™) for the treatment of early and intermediate stage Hepatocellular Carcinoma (HCC) not amenable for curative treatments. Distribution of the microspheres was correlated with results post embolization. MATERIALS AND METHODS: This was a prospective, single arm, open label study. The primary outcome measures were distribution of the radiopaque microspheres as showed by computerized tomography (CT) and local response measured by modified Response Evaluation Criteria (mRECIST) after Magnetic Resonance Imaging (MRI). Secondary measures were Time to Progression (TTP) and Overall Survival (OS). RESULTS: Fifty patients were enrolled over 36 months. Median age was 69.0 years; mean sum of target lesions diameters was 78.6 ± 36.8 mm. There were no Grade 4 or 5 adverse events (AEs). At 6 months Complete Response (CR) (18%), Partial Response (PR) (62%), Objective Response OR (80%) and Stable Disease (SD) (20%) were recorded. Before embolization, Diffusion Weighted Imaging (DWI) showed high signal (restricted diffusion). Post procedure, patients with dense deposition (< 5 mm distance of microsphere aggregations) showed 100% absence of enhancement and no restriction in 30.6%. Median TTP was 8.3 months. TTP for patients with CR was 13.3 months and 7.2 and 5.6 for PR and SD, respectively. At 6 and 36 months, survival was 94% and 34%, respectively. CONCLUSION: DC Bead LUMI™ is well tolerated and effective in early and intermediate stage HCC with maximal necrosis obtained in dense deposition in the target.

Role of interventional radiology in pain management in oncology patients.

This article reviews the current evidence of interventional radiology procedures for patients suffering with debilitating cancer pain, refractory to conventional therapies. Cancer pain is notoriously difficult to treat. Up to 90% of cancer patients experience pain with 56-82% of cancer pain controlled inadequately. Cancer pain influences a patient's ability to perform normal daily activities, causes higher risk of depression, and reduces quality of life. Pain-free status has been universally voted as a "good death". Alternative minimally invasive options include nerve blocks, neurolysis, bone ablation, spine and peripheral musculoskeletal augmentation techniques, embolisation, and cordotomy with evidence highlighting improved pain control, reduced analgesic requirements, and improved quality of life. Unfortunately, awareness and availability of these procedures is limited, potentially leaving patients suffering during their remaining life. The purpose of this review is to describe the basic concepts of interventional radiology techniques for pain palliation in oncology patients. In addition, emphasis will be given upon the need for an individually tailored approach aiming to augment efficacy and safety.

Intra-Articular Application of Sluijter-Teixera Poisson Pulsed Radiofrequency in Symptomatic Patients with Knee Osteoarthritis: Focus upon Clinical Efficacy and Safety.

Purpose: To retrospectively evaluate the effectiveness of intra-articular application of Sluijter-Teixera Poisson pulsed radiofrequency (STP PRF) in knee osteoarthritis symptomatic patients with chronic pain refractory to conservative therapies. Materials and Methods: Institutional database research of two centers identified 39 cases of knee osteoarthritis patients treated with intra-articular STP PRF. Pain prior and one-week and one-, three-, six-, and twelve-month post-STP PRF was compared by means of a numeric visual scale (NVS) questionnaire. Cardiovascular and Interventional Radiological Society of Europe (CIRSE) classification system was used for complications reporting. Mean patient age was 71.59 ± 11.99 years, mean body mass index was 30.23 ± 4.69, and male/female ratio was 9/30. Results: Mean baseline pain score was 8.31 ± 1.70 NVS units. This was reduced to a mean value of 0.90 ± 1.50 NVS units one-week post-RF, 1.08 ± 1.53 at one month, 1.54 ± 1.88 at three months, 2.33 ± 2.17 at six months, and 3.23 ± 2.23 at 12 months of follow-up (p < 0.01). Pain decrease of more than 4 NVS units was noticed in 35/39 knees (89.7%) at first week, 36/39 knees (92.3%) at first month, 35/39 knees (89.7%) at three months, 32/39 knees (82.1%) at six months, and 25/39 knees (64.1%) at one year. There was no recurrence during the follow-up. No complication was observed. Conclusions: Percutaneous, intra-articular application of STP PRF is an effective and safe technique for chronic pain reduction in patients with knee osteoarthritis. Results seem to be reproducible and long lasting with significant patient satisfaction at 12-month follow-up.

Percutaneous computed tomography-guided radiofrequency ablation of a spinal osteoid osteoma abutting the dura: a case report and review of the literature.

PURPOSE: Osteoid osteomas in the spine constitute a challenging group for both surgical and percutaneous approaches. Purpose of the present study is to report a case report of a spinal osteoid osteoma in a challenging spinal location and review literature for safety and efficacy of the technique. METHODS: We report a case of spinal osteoid osteoma extending in the epidural space and abutting the dura in a pediatric patient treated by percutaneous computed tomography-guided radiofrequency ablation. This is not a systematic review of the literature. A number of separate literature searches were performed. Non-English studies and case reports were excluded from the study. All references of the obtained articles were also evaluated for any additional information. RESULTS: Although all prophylactic measures were taken (hydrodissection, thermocouples and neurophysiologic monitoring) and the procedure was uneventful, patient within three hours, was unable to raise or bend the unilateral lower extremity below the knee. Pain reduction was significant from the first morning post-ablation and during the follow-up period of 18 months. MR scan was within normal limits. Dexamethasone was iv injected for 24 h and prescribed per os for 7 days. At follow-up 1 week later mobility of the lower extremity had returned to normal. CONCLUSION: As far as spine ablation is concerned, all prophylactic measures should be taken; neurophysiologic monitoring seems to be more sensitive than temperature measurement. Intravenous and per os corticosteroids are extremely useful in case of nerve damage.

A Technical Report on the Performance of Percutaneous Cryoneurolysis of Splanchnic Nerves for the Treatment of Refractory Abdominal Pain in Patients with Pancreatic Cancer: Initial Experience.

PURPOSE: To report our preliminary results upon feasibility, efficacy and safety of percutaneous splanchnic nerves cryoneurolysis for the treatment of abdominal pain refractory to conservative medication in patients with pancreatic cancer MATERIALS METHODS: Institutional database research (retrospective review of prospectively collected data from April 2019 till August 2020) identified 5 patients with pancreatic cancer and pain refractory to conservative medication who underwent percutaneous cryoneurolysis of splanchnic nerves. In all patients, percutaneous cryoneurolysis was performed with posterolateral paravertebral approach using a 17 Gauge cryoprobe under computed tomography guidance and local anesthesia. Self-reported pain scores were assessed before and at the last follow-up using a pain inventory with visual analog scale (VAS) units. RESULTS: Mean patient age was 63.81 years (male-female: 3-2). Mean pain score prior to cryoanalgesia of splanchnic nerves was 9.4 VAS units. This score was reduced to a mean value of 2.6, 2.6 and 3 VAS units at 1, 3 and 6 months of follow-up, respectively. All patients reported significantly reduced analgesic usage. No complication was reported according to the CIRSE classification system. The mean procedure time was 44.4 min (range 39-50 min), including local anesthesia, cryoprobe(s) placement, ablation and post-procedural CT evaluation. CONCLUSION: Percutaneous cryoanalgesia of the splanchnic nerves is a minimally invasive, safe and effective procedure for pancreatic cancer pain relief. A larger, randomized trial is justified to substantiate these findings.

Percutaneous imaging-guided techniques for the treatment of benign neuropathic pain.

To date, conservative management including physical and/or systemic pharmacologic therapy is considered as the first line approach for the management of neuropathic pain syndromes. In the era of an opioid overdose crisis with an increased concern upon the risks and harms arising from the misuse of medicines for pain management, percutaneous minimally invasive techniques such as nerve infiltrations as well as neurolysis or neuromodulation techniques can be proposed to control pain and improve life quality. Computed tomography can serve as an ideal guiding technique due to its specific characteristics including precise anatomic delineation, high spatial resolution and good tissue contrast. The purpose of this review is to make the reader familiar with the most common indications for minimally invasive imaging-guided techniques in patients with neuralgia and provide current evidence regarding technical considerations.

RADIATION DOSES TO THE EYE LENS AND FOREHEAD OF INTERVENTIONAL RADIOLOGISTS: HOW HIGH AND ON WHAT GROUNDS?

The aim of the study was to measure and evaluate the radiation dose to the eye lens and forehead of interventional radiologists (IRs). The study included 96 procedures (lower-limb percutaneous transluminal angioplasties, embolisations/chemoembolisations and vertebroplasties) performed by 6 IRs. A set of seven thermoluminescence dosemeters was allocated to each physician. The highest dose per procedure was found for the left eye lens of the primary operator in vertebroplasties (1576 µSv). Left and right eye doses were linearly correlated to left and right forehead doses, respectively. A workload-based estimation of the annual dose to participating IRs revealed that the occupational dose limit for the eye lens can be easily exceeded. The left eye dose of ΙRs must be routinely monitored on a personalised basis. Τhe left eye dose measurement provides a reliable assessment of the ipsilateral forehead dose, along with valid estimations for the right eye and right forehead doses.

Computed-tomography-guided transforaminal intrathecal nusinersen injection in adults with spinal muscular atrophy type 2 and severe spinal deformity. Feasibility, safety and radiation exposure considerations.

BACKGROUND AND PURPOSE: The purpose was to investigate our centre's experience on computed-tomography-guided (CT-guided), transforaminal, intrathecal administration of nusinersen in adult subjects with spinal muscular atrophy (SMA) type 2 and severe spinal deformity. METHOD: This is a retrospective, single-centre study investigating the feasibility and safety of CT-guided, transforaminal, lumbar puncture for the intrathecal administration of nusinersen (Spinranza®; Biogen; Cambridge, MA, USA) in a cohort of adult subjects with SMA type 2, severe neuromuscular scoliosis and previous spinal surgery. Between January 2019 and October 2019, five male, adult, SMA type 2 subjects were eligible to be treated in our centre with nusinersen. The mean age of the patients was 31 ± 9 years (range 19-43 years). The study's outcome measures were technical success, adverse events and radiation exposure. RESULTS: In total, four patients completed the four loading doses, whilst the fifth patient received only one loading dose; two patients also received their first maintenance doses. Overall, 20 consecutive transforaminal, intrathecal treatments were analysed. Technical success was 100% (20/20 intrathecal infusions). No adverse events were documented following the procedures. Mean dose-length product (DLP) value per injection was 665.4 ± 715.5 mGy*cm. Estimated mean effective dose per injection was 12.7 ± 12.9 mSv. Subgroup analysis between the chronologically first 10 versus subsequent 10 procedures demonstrated a clear trend towards less radiation exposure in the latter, although this difference did not reach statistical significance (DLP: 984.7 ± 903.3 vs. 436.7 ± 321.5 mGy*cm, P = 0.165; respectively). CONCLUSIONS: In this retrospective series, CT-guided transforaminal access for intrathecal injection of nusinersen was proven feasible and safe. A decrease in radiation dose over time was noted. Protocols to minimize radiation exposure are essential.

Computed Tomography-Guided Percutaneous Infiltrations for Piriformis Syndrome: A Single-Center Retrospective Study.

Piriformis syndrome (PS), first described by Yeoman in 1928, is a general term referring to low back pain, sciatica, and instability. PS has a 6% incidence rate worldwide. In this study, we aim to retrospectively evaluate the effectiveness of computed tomography (CT)-guided percutaneous infiltration in a series of consecutive PS patients who have symptoms that are refractory to conservative therapies. An institutional database search identified 20 such consecutive patients who underwent infiltration with a mixture of long-acting corticosteroid and local anesthetic. Preoperational evaluation included physical examination and magnetic resonance imaging. The correct position of the 22-gauge spinal needle was verified with CT scan after contrast medium injection. Pain measured before the procedure and at 1 wk and 1, 6, and 12 mo after the procedure was compared by means of a numeric visual scale (NVS) questionnaire. The mean pain score before CT-guided percutaneous infiltration was 8.95 ± 1.432 NVS units. This score was reduced to a mean value of 0.85 ± 0.933 units at 1 wk, 0.90 ± 0.852 at 1 mo, 1.10 ± 1.165 at 6 mo, and 1.20 ± 1.399 at 12 mo follow-up (p < 0.001). Two patients of 20 (10%) underwent a second infiltration that was performed at 7 and 10 d after the first, respectively. No complications were observed. CT-guided infiltration seems to be a feasible, efficacious, and safe approach for pain reduction and mobility improvement in patients with symptomatic PS.

Percutaneous ablation techniques for renal cell carcinoma: current status and future trends.

Percutaneous ablation is an increasingly applied technique for the treatment of localized renal tumors, especially for elderly or co-morbid patients, where co-morbidities increase the risk of traditional nephrectomy. Ablative techniques are technically suited for the treatment of tumors generally not exceeding 4 cm, which has been set as general consensus cutoff and is described as the upper threshold of T1a kidney tumors. This threshold cutoff is being challenged, but with still limited evidence. Percutaneous ablation techniques for the treatment of renal cell carcinoma (RCC) include radiofrequency ablation, cryoablation, laser or microwave ablation; the main advantage of all these techniques over surgery is less invasiveness, lower complication rates and better patient tolerability. Currently, international guidelines recommend percutaneous ablation either as intervention for frail patients or as a first line tool, provided that the tumor can be radically ablated. The purpose of this article is to describe the basic concepts of percutaneous ablation in the treatment of RCC. Controversies concerning techniques and products and the need for patient-centered tailored approaches during selection among the different techniques available will be discussed.

Interventional radiology techniques for pain reduction and mobility improvement in patients with knee osteoarthritis.

Osteoarthritis of the knee is the most common cause of chronic knee pain being more prevalent in middle-aged and elderly patients. Symptomatic patients complain of pain and mobility impairment. Therapeutic armamentarium includes physical therapy, oral pharmacologic therapy, intra-articular injections, nerve ablation or modulation, trans-catheter arterial embolization, minimally invasive arthroscopic treatment and partial or total knee arthroplasty. Interventional radiology therapies for knee osteoarthritis include intra-articular injections, neurotomy and neuromodulation techniques as well as transcatheter intra-arterial therapies. These therapies aim to control pain and inflammation, improve mobility and function whilst the novel cell-based therapies have the potential for bone and cartilage regenerative repair facilitating the delay to surgery. The purpose of this review is to illustrate the technical aspects, the indications and the methodology of local therapies for knee osteoarthritis performed by interventional radiologists and provide current evidence.

Intra-articular application of pulsed radiofrequency combined with viscosupplementation for improvement of knee osteoarthritis symptoms: a single centre prospective study.

OBJECTIVES: To prospectively evaluate the effectiveness of intra-articular application of pulsed radiofrequency (PRF) combined with viscosupplementation in patients with knee osteoarthritis suffering from chronic pain refractory to conservative therapies. METHODS: During a 30-month period, PRF combined with viscosupplementation was performed on 53 cases of knee osteoarthritis (45 patients, 8/45 with bilateral knee osteoarthritis). Pre-operational imaging included standard knee X-rays on anterior-posterior and lateral views used to evaluate patients according to the Kellgren-Lawrence classification. Pain, prior, one week/one, 6 and 12 months post were compared by means of a numeric visual scale (NVS) questionnaire. RESULTS: Mean pain score prior to PRF was 8.19 ± 1.4 NVS units. This score was reduced to a mean value of 2.47 ± 2.5 NVS units at 1 week after, 2.55 ± 2.6 at 1 month, 3.1 ± 2.8 at 6 months and 5.02 ± 3.09 at 12 months of follow-up (p < 0.01). Overall mobility improved in 47/53 (88.6%) patients. No complication was observed. CONCLUSIONS: Combining PRF with viscous supplementation is an effective and safe technique for palliative management of chronic pain in patients with knee osteoarthritis. Results seem to be reproducible and long lasting. There seems to be a need of repeating the session at 1 year.

Percutaneous microwave ablation of renal cell carcinoma using a high power microwave system: focus upon safety and efficacy.

OBJECTIVES: Percutaneous ablation is an expanding, minimally invasive approach for small- to medium-sized renal masses. The purpose of this study is to review safety, and mid-term efficacy of percutaneous microwave ablation (MWA) for Renal Cell Carcinoma (RCC) treatment using a high power microwave system. METHODS AND MATERIALS: Institutional database research identified 50 consecutive patients with a single lesion resembling renal cell carcinoma in CT and MRI who underwent percutaneous microwave ablation using a high power microwave system. All patients underwent biopsy on the same session with ablation using an 18G semi-automatic soft tissue biopsy needle. Contrast-enhanced computed tomography or magnetic resonance imaging was used for post-ablation follow-up. Patient and tumour characteristics, microwave technique, complications and pattern of recurrence were evaluated. RESULTS: Mean patient age was 74 years (male-female: 31-19). Average lesion size was 3.1 cm (range 2.0-4.3 cm). Biopsy results report RCC (n = 48), inflammatory myofibroblastic tumour (n = 1), and non-diagnostic sample (n = 1). The 3-year overall survival was 95.8% (46/48). Two patients died during the 3-year follow-up period due to causes unrelated to the MW ablation and to the RCC. Minor complications including haematomas requiring nothing but observation occurred at 4% (2/50) of the cases. Local recurrence of 6.25% (3/48) was observed with 2/3 cases being re-treated achieving a total clinical success of 97.9% (47/48 lesions). CONCLUSIONS: Percutaneous microwave ablation of RCC using a high power microwave system is a safe and efficacious technique for the treatment of small- to medium-sized renal masses.

Pain management: The rising role of interventional oncology.

Patients with early or metastatic cancer may suffer from pain of different origins. The vast majority of these patients are not adequately treated by means of systemic analgesia and radiotherapy. Percutaneous neurolysis is performed using chemical agents or thermal energy upon sympathetic nervous system plexus for pain reduction and life quality improvement. Ablation and vertebral augmentation are included in clinical guidelines for metastatic disease. As far as the peripheral skeleton is concerned bone augmentation and stabilization can be performed by means of cement injection either solely performed or in combination to cannulated screws or other metallic or peek implants. This review describes the basic concepts of interventional oncology techniques as therapies for cancer pain management. The necessity for a tailored-based approach applying different techniques for different cases and locations will be addressed.

Cirse Quality Assurance Document and Standards for Classification of Complications: The Cirse Classification System.

Interventional radiology provides a wide variety of vascular, nonvascular, musculoskeletal, and oncologic minimally invasive techniques aimed at therapy or palliation of a broad spectrum of pathologic conditions. Outcome data for these techniques are globally evaluated by hospitals, insurance companies, and government agencies targeting in a high-quality health care policy, including reimbursement strategies. To analyze effectively the outcome of a technique, accurate reporting of complications is necessary. Throughout the literature, numerous classification systems for complications grading and classification have been reported. Until now, there has been no method for uniform reporting of complications both in terms of definition and grading. The purpose of this CIRSE guideline is to provide a classification system of complications based on combining outcome and severity of sequelae. The ultimate challenge will be the adoption of this system by practitioners in different countries and health economies within the European Union and beyond.

Computed tomography-guided radiofrequency ablation of intra-articular osteoid osteoma: a single centre's experience.

OBJECTIVE: To evaluate safety and efficacy of radiofrequency ablation (RFA) in the treatment of painful intra-articular osteoid osteoma. MATERIALS AND METHODS: During the last 3 years, 15 patients underwent computed tomography (CT)-guided biopsy and RFA of symptomatic intra-articular osteoid osteoma. In order to assess and sample the nidus, a coaxial bone biopsy system was used. Biopsy was performed and followed by ablation session with osteoid osteoma protocol in all cases. Procedure time (i.e. drilling including local anaesthesia and ablation), amount of scans, the results of biopsy and pain reduction during follow-up period are reported. RESULTS: Access to the nidus through normal bone, biopsy and electrode insertion was technically feasible in all cases. Median procedure time was 54 min. Histologic verification of osteoid osteoma was performed in all cases. Median amount CT scans, performed to control correct positioning of the drill and precise electrode placement within the nidus was 9. There were no complications or material failure reported in our study. There was no need for protective techniques of the articular cartilage. Pain reduction was significant from the first morning post ablation and complete at the one week and during the follow-up period. No recurrences were noted. CONCLUSIONS: RFA under CT guidance is a safe and efficient technique for the treatment of painful intra-articular osteoid osteoma. Imaging guidance, extra-articular access through normal bone and exact positioning of the needle-electrode inside the nidus facilitate safety of the technique and prevention of damage to the articular cartilage.