Innovations in Image-Guided Procedures: Unraveling Robot-Assisted Non-Hepatic Percutaneous Ablation.

Interventional oncology is routinely tasked with the feat of tumor characterization or destruction, via image-guided biopsy and tumor ablation, which may pose difficulties due to challenging-to-reach structures, target complexity, and proximity to critical structures. Such procedures carry a risk-to-benefit ratio along with measurable radiation exposure. To streamline the complexity and inherent variability of these interventions, various systems, including table-, floor-, gantry-, and patient-mounted (semi-) automatic robotic aiming devices, have been developed to decrease human error and interoperator and intraoperator outcome variability. Their implementation in clinical practice holds promise for enhancing lesion targeting, increasing accuracy and technical success rates, reducing procedure duration and radiation exposure, enhancing standardization of the field, and ultimately improving patient outcomes. This narrative review collates evidence regarding robotic tools and their implementation in interventional oncology, focusing on clinical efficacy and safety for nonhepatic malignancies.

Impact of Percutaneous Cryoablation on Renal Function in Patients with Stage I Renal Cell Carcinoma: A Systematic Review and Meta-Analysis.

PURPOSE: To assess the effect of cryoablation on renal function (measured by estimated glomerular filtration rate [eGFR] or serum creatinine) for treating Stage I renal cancer. MATERIALS AND METHODS: The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were systematically searched from inception to May 1, 2023. Cohort studies that included data on change of eGFR and serum creatinine increase were included. Meta-analysis was performed by measuring the weighted mean difference and by fitting random-effect models. RESULTS: Overall, 38 studies were included, comprising 3,202 participants. Percutaneous cryoablation was associated with an absolute eGFR reduction of -3.06 mL/min/1.73 m2 (95% CI, -4.12 to -2.01; P < .001) and serum creatinine increase of 0.05 mg/dL (95% CI, -0.02 to 0.11; P > .05). The weighted absolute mean difference of percutaneous cryoablation for treating Stage T1b renal cell carcinoma was estimated at -5.19 mL/min/1.73 m2 (95% CI, -11.1 to 0.72; P > .05). Lastly, when analyzing studies that included cohorts with solitary kidneys, the pooled weighted mean difference was estimated as -3.27 mL/min/1.73 m2 (95% CI, -6.79 to 0.25; P > .05). CONCLUSIONS: Percutaneous cryoablation for Stage 1 renal cell carcinoma has minimal significant impact on renal function (measured by eGFR or serum creatinine). The same outcome was observed in patients with larger tumors (T1b) and those with solitary kidneys.

Magnetic resonance-guided focused ultrasound versus percutaneous thermal ablation in local control of bone oligometastases: a systematic review and meta-analysis.

BACKGROUND: The percutaneous thermal ablation techniques (pTA) are radiofrequency ablation, cryoablation, and microwave ablation, suitable for the treatment of bone oligometastases. Magnetic resonance-guided focused ultrasound (MRgFUS) is a noninvasive ablation technique. OBJECTIVES: To compare the effectiveness and safety of MRgFUS and pTA for treating bone oligometastases and their complications. METHODS: Studies were selected with a PICO/PRISMA protocol: pTA or MRgFUS in patients with bone oligometastases; non-exclusive curative treatment. Exclusion criteria were: primary bone tumor; concurrent radiation therapy; palliative therapy; and absence of imaging at follow-up. PubMed, BioMed Central, and Scopus were searched. The modified Newcastle-Ottawa Scale assessed articles quality. For each treatment (pTA and MRgFUS), we conducted two separate random-effects meta-analyses to estimate the pooled effectiveness and safety. The effectiveness was assessed by combining the proportions of treated lesions achieving local tumor control (LTC); the safety by combining the complications rates of treated patients. Meta-regression analyses were performed to identify any outcome predictor. RESULTS: A total of 24 articles were included. Pooled LTC rate for MRgFUS was 84% (N = 7, 95% CI 66-97%, I2 = 74.7%) compared to 65% of pTA (N = 17, 95% CI 51-78%, I2 = 89.3%). Pooled complications rate was similar, respectively, 13% (95% CI 1-32%, I2 = 81.0%) for MRgFUS and 12% (95% CI 8-18%, I2 = 39.9%) for pTA, but major complications were recorded with pTA only. The meta-regression analyses, including technique type, study design, tumor, and follow-up, found no significant predictors. DISCUSSION: The effectiveness and safety of the two techniques were found comparable, even though MRgFUS is a noninvasive treatment that did not cause any major complication. Limited data availability on MRgFUS and the lack of direct comparisons with pTA may affect these findings. CONCLUSIONS: MRgFUS can be a valid, safe, and noninvasive treatment for bone oligometastases. Direct comparison studies are needed to confirm its promising benefits.

Patient Dose Estimation in Computed Tomography-Guided Biopsy Procedures.

This study establishes typical Diagnostic Reference Levels (DRL) values and assesses patient doses in computed tomography (CT)-guided biopsy procedures. The Effective Dose (ED), Entrance Skin Dose (ESD), and Size-Specific Dose Estimate (SSDE) were calculated using the relevant literature-derived conversion factors. A retrospective analysis of 226 CT-guided biopsies across five categories (Iliac bone, liver, lung, mediastinum, and para-aortic lymph nodes) was conducted. Typical DRL values were computed as median distributions, following guidelines from the International Commission on Radiological Protection (ICRP) Publication 135. DRLs for helical mode CT acquisitions were set at 9.7 mGy for Iliac bone, 8.9 mGy for liver, 8.8 mGy for lung, 7.9 mGy for mediastinal mass, and 9 mGy for para-aortic lymph nodes biopsies. In contrast, DRLs for biopsy acquisitions were 7.3 mGy, 7.7 mGy, 5.6 mGy, 5.6 mGy, and 7.4 mGy, respectively. Median SSDE values varied from 7.6 mGy to 10 mGy for biopsy acquisitions and from 11.3 mGy to 12.6 mGy for helical scans. Median ED values ranged from 1.6 mSv to 5.7 mSv for biopsy scans and from 3.9 mSv to 9.3 mSv for helical scans. The study highlights the significance of using DRLs for optimizing CT-guided biopsy procedures, revealing notable variations in radiation exposure between helical scans covering entire anatomical regions and localized biopsy acquisitions.

Percutaneous microwave ablation of hepatic tumors: is there an impact of cirrhotic liver parenchyma upon the volume and short-term assessment of the ablation zone?

OBJECTIVE: To retrospectively compare and evaluate ablation zone volume and its reduction from baseline to 1 month follow-up post-percutaneous microwave ablation (MWA) between healthy and cirrhotic liver parenchyma. METHODS: Institutional database research identified 84 patients (118 hepatic tumors) who underwent percutaneous MWA with the same system. Caudal-right lobe ratio was applied to distinguish cirrhotic (n = 51) and healthy (n = 67) group; ITK-SNAP software was used to quantify ablation zone volume. Long (LAD) and short 1 (SAD-1) and 2 (SAD-2) axis, tumor size diameter (mm) and volume (cm³) of the ablation zones were evaluated for each treated lesion in both groups at baseline (immediately post-ablation) and at 1 month follow-up. RESULTS: There was no significant difference comparing ablation zone volumes at baseline (healthy group: mean ablation volume 14.84 cm³ vs cirrhotic group: mean ablation volume 17.85 cm³, p = 0.31) and 1 month post-ablation (healthy group: mean ablation volume 9.15 cm³ vs cirrhotic group: mean ablation volume 11.58 cm³, p = 0.24). When both "healthy" and "cirrhotic" liver group were evaluated independently, there was a significant difference of ablation volumes reduction (p-value < 0.001) from baseline to 1 month follow-up. When both groups were compared based on reduction (35.12-38.34%) there was no significant difference in ablation zone volumes (p-value = 0.77). CONCLUSION: Percutaneous MWA results in ablation zones of a comparable volume in both healthy and cirrhotic liver parenchyma. Both cirrhotic and healthy liver parenchyma experience a similar significant reduction of ablation zone volume at 1 month post-therapy. ADVANCES IN KNOWLEDGE STATEMENT: This study evaluates and compares the volume of the ablation zone after MWA between healthy and cirrhotic liver parenchyma from baseline to 1 month follow-up and attempts to identify potential differences. It is the first study to demonstrate significant shrinkage of ablation volumes in healthy livers as compared to cirrhotic livers after 4 weeks of follow-up. The results of this study can help us understand the effect of MWA when applied in different backgrounds of liver parenchyma, which could lead to different treatment planning.

Intradiscal Gelified Ethanol Nucleolysis versus Endoscopic Surgery for Lumbar Disc Herniation Radiculopathy.

The purpose of this study was to retrospectively compare efficacy and safety between intradiscal injection of a gelified ethanol product and tubular discectomy in the treatment of intervertebral disk herniation. A bi-central institutional database research identified forty (40) patients suffering from symptomatic contained disc herniation. Nucleolysis Group included 20 patients [mean 50.05 ± 9.27 years-of-age (male/female 14/6-70/30%)] and Surgery Group included 20 patients [mean 48.45 ± 14.53 years-of-age, (male/female 12/8-60/40%)]. Primary outcome was overall 12-month improvement over baseline in leg pain (NVS units). Procedural technical outcomes were recorded, and adverse events were evaluated at all follow-up intervals. CIRSE classification system was used for complications' reporting. Mean pre-operative pain score in Nucleolysis Group was 7.95 ± 0.94 reduced to 1.25 ± 1.11 at month 1 and 0.45 ± 0.75 NVS units at year 1. Mean pre-operative pain score in Surgery Group was 7.65 ± 1.13 reduced to 1.55 ± 1.79 at month 1 and 0.70 ± 1.38 NVS units at year 1. Pain decrease was statistically significant after both procedures (p < 0.001). There was no statistically significant difference between pain reduction in both groups (p = 0.347). The decrease differences of the pain effect upon general activities, sleeping, socializing, walking, and enjoying life in the follow-up period between the two groups were not statistically significant. No complications were noted in both groups. Results from the current study report that intradiscal injection of a gelified ethanol and tubular discectomy were equally effective on terms of efficacy and safety for the treatment of symptomatic lumbar intervertebral disc herniation regarding the 12-month mean leg pain improvement. Both achieved similar rapid significant clinical improvement persisting throughout follow-up period.

Comprehensive Palliative Musculoskeletal Interventional Radiology Care for Patients with Cancer.

Substantial advances in percutaneous image-guided minimally invasive musculoskeletal oncologic interventions offer a robust armamentarium for interventional radiologists for management of cancer. The authors outline the most recent advances in such interventions and the role of interventional radiologists in managing cancer in modern-era practice. Percutaneous minimally invasive musculoskeletal interventions including thermal ablation, cementation with or without osseous reinforcement by implants, osteosynthesis, neurolysis, and embolization, as well as palliative injections, have been successfully used by interventional radiologists to achieve durable, timely, safe, effective palliation in a multidisciplinary setting and have been progressively incorporated into the management paradigm for patients with cancer with musculoskeletal involvement. Familiarity with the described interventions and implementation of procedural safety measures, combined with integration of these procedures into clinical practice with the support of the National Comprehensive Cancer Network and the American College of Radiology, as well as continued technologic advances in procedural equipment design, will further enhance the role of interventional radiologists in cancer management. ©RSNA, 2022.

Vertebral Augmentation: Is It Time to Get Past the Pain? A Consensus Statement from the Sardinia Spine and Stroke Congress.

Vertebral augmentation has been used to treat painful vertebral compression fractures and metastatic lesions in millions of patients around the world. An international group of subject matter experts have considered the evidence, including but not limited to mortality. These considerations led them to ask whether it is appropriate to allow the subjective measure of pain to so dominate the clinical decision of whether to proceed with augmentation. The discussions that ensued are related below.

Update on Interventional Radiology of the Spine.

Interventional radiologists now perform spinal interventions routinely for diagnostic and therapeutic purposes. New technologies for the management of spine pathologies have emerged with promising results in terms of safety and efficacy. Interventional radiology techniques in the spine include percutaneous biopsy and therapies for intervertebral disk herniation or spinal stenosis, facet and sacroiliac joint pathologies, vertebral and sacral fractures, and metastases. These techniques can also be easily combined one with the other or to further therapeutic approaches including systemic therapies, surgical approaches, and radiotherapy. This review provides a comprehensive overview of current percutaneous imaging-guided interventional radiology techniques in the spine. It will help readers become familiar with the most common indications, learn about different technical considerations during performance, and review the available evidence. Controversies concerning new products and technical approaches are also addressed.

Interventional oncology procedures for breast cancer metastatic disease: current role and clinical applications.

Worldwide, breast cancer constitutes the most common malignant neoplasm among females, impacting 2.1 million women annually. Interventional oncology techniques have been recently added as an additional therapeutic and palliative alternative in breast cancer metastatic disease, concerning mainly osseous, liver, and lung metastasis. In the current literature, there are reports of promising results and documented efficacy regarding the ablation of liver and lung metastasis from breast carcinoma, transarterial embolization or radioembolization, as well as the treatment of osseous metastatic disease. These literature studies are limited by the heterogeneity of breast cancer disease, the evaluation of variable different parameters, as well as the retrospective nature in most of the cases. Consequently, dedicated prospective series and randomized studies are required to identify the role of minimally invasive local therapies of interventional oncology armamentarium. The present review paper focuses upon the current role of interventional oncology techniques for the curative or palliative treatment of metastatic breast cancer disease. The purpose of this review paper is to present the current minimally invasive procedures in the treatment of metastatic breast disease, including local control rates and survival rates.

Percutaneous Ablation of Metastatic Lymph Nodes: An Insight from the Comparison of Efficacy and Safety Between Cryoablation and Radiofrequency Ablation.

PURPOSE: To retrospectively compare efficacy and safety of computed tomography (CT)-guided percutaneous ablation of metastatic lymph nodes (LN) between cryoablation (CA) and radiofrequency ablation (RFA). MATERIALS AND METHODS: A bi-central institutional database research identified 28 patients (42 metastatic LNs) who underwent percutaneous CT-guided ablation. RFA group included 18 patients/26 tumors; CA group included 10 patients/16 tumors. Contrast-enhanced CT or MRI was used for post-ablation follow-up. Patient and tumor characteristics, technical and clinical success on a per tumor and a per patient basis and complication rates were recorded, evaluated and compared between the 2 groups. RESULTS: Both RFA and CA groups had the same median tumor size (2.00 vs. 2.20 cm, p = 0.257), the same median follow-up time (20.50 vs. 20.00 months, p = 0.923) and the same median length of hospital stay (1.00 vs. 1.00 days, p = 0.283). CA group had a higher median procedure time (110.50 vs. 52.00 min, p = 0.001). On a per lesion basis, the overall complete response post-ablation was 88.46% (23/26 lesions) in the RFA and 93.75% (15/16 lesions) in the CA group; no association was revealed between local tumor control and ablation technique (p = 0.709). No complications were recorded in both Groups. On a per patient basis, CA had a longer disease-free interval (24.00 vs. 14.50, p = 0.012) which, however, did not affect the overall survival between the two techniques (26.0 vs. 22.0, p = 0.099 for CA and RFA respectively). CONCLUSION: Our limited data suggest that CT-guided RFA and CA are equally effective on terms of efficacy and safety for the treatment of metastatic lymph nodes.

Percutaneous Navigation under Local Anesthesia for Computed Tomography-Guided Microwave Ablation of Malignant Liver Lesions Located in the Hepatic Dome.

Background and Objectives: The aim of the present study was to report the safety and efficacy of percutaneous navigation under local anesthesia for computed tomography-guided microwave ablation of malignant liver lesions located in the hepatic dome. Patients with primary and secondary malignant liver lesions located in the hepatic dome who underwent percutaneous computed tomography-guided microwave ablation using a computer-assisted navigation system under local anesthesia were prospectively evaluated. The primary objective was technical success. Materials and Methods: The sample consisted of 10 participants (16 lesions) with a mean age of 60.60 years (SD = 9.25 years) and a mean size of 20.37 ± 7.29 cm, and the mean follow-up time was 3.4 months (SD = 1.41) months. Results: Primary technical success was 93.75%. Tumor remnant was noticed at one month follow-up in a single metastatic lesion, which was re-treated with an ablation session, and no tumor remnant was depicted in the subsequent imaging follow-up (secondary technical success 100%). Grade I self-limited complications (according to the CIRSE classification system) included small pleural effusion (n = 1) and minor bleeding post antenna removal (n = 1) requiring nothing but observation. Conclusions: the findings of the present study indicate that percutaneous navigation under local anesthesia is a safe and efficacious approach for computed tomography-guided microwave ablation of malignant liver lesions located in the hepatic dome. Large randomized controlled studies are warranted to observe treatment effectiveness and compare the results with those of other options.

MRI evidence of extraocular muscle atrophy and fatty replacement in myasthenia gravis.

PURPOSE: The aim of the study was to evaluate extraocular muscle (EOM) atrophy and fatty replacement in ocular myasthenia gravis (OMG) and generalized myasthenia gravis (GMG) patients with chronic and untreated ocular symptoms or with inadequate response to immunotherapy and unprovoked ocular exacerbations despite chronic immunotherapy. METHODS: Nineteen patients with either OMG or GMG and 19 healthy age-matched controls underwent an orbital MRI. Visually obvious muscle atrophy and muscle fatty replacement were evaluated by two raters independently. Maximum thickness of EOM was measured. Measurements of the muscles of each participant were added up, in order to calculate the total thickness. RESULTS: Eleven patients suffered from AChR-positive GMG, and 8 patients from OMG. All patients had chronic ocular symptoms or inadequate response to corticosteroids and unprovoked ocular exacerbations in spite of immunotherapy. Fatty replacement was reported in 6/19 (31.6%) patients and 0/19 (0%) controls (p = 0.02). Obvious atrophy in at least one muscle was reported in 8/19 (42.1%) patients and 1/19 (5.3%) controls (p = 0.019). Statistically significant differences between the two groups were also found in the mean total thickness, as well as in the thickness of superior recti, levator palpebrae, inferior recti, and superior oblique muscles. CONCLUSION: EOM atrophy and fatty replacement were seen frequently in our series of MG patients with treatment difficulties and frequent relapses of ocular involvement.

The Role of Percutaneous Ablation in the Management of Colorectal Cancer Liver Metastatic Disease.

Approximately 50% of colorectal cancer patients will develop metastases during the course of the disease. Local or locoregional therapies for the treatment of liver metastases are used in the management of oligometastatic colorectal liver disease, especially in nonsurgical candidates. Thermal ablation (TA) is recommended in the treatment of limited liver metastases as free-standing therapy or in combination with surgery as long as all visible disease can be eradicated. Percutaneous TA has been proven as a safe and efficacious therapy offering sustained local tumor control and improved patient survival. Continuous technological advances in diagnostic imaging and guidance tools, the evolution of devices allowing for optimization of ablation parameters, as well as the ability to perform margin assessment have improved the efficacy of ablation. This allows resectable small volume diseases to be cured with percutaneous ablation. The ongoing detailed information and increasing understanding of tumor biology, genetics, and tissue biomarkers that impact oncologic outcomes as well as their implications on the results of ablation have further allowed for treatment customization and improved oncologic outcomes even in those with more aggressive tumor biology. The purpose of this review is to present the most common indications for image-guided percutaneous ablation in colorectal cancer liver metastases, to describe technical considerations, and to discuss relevant peer-reviewed evidence on this topic. The growing role of imaging and image-guidance as well as controversies regarding several devices are addressed.

Percutaneous Management of Cancer Pain.

PURPOSE OF REVIEW: To describe several effective imaging-guided, minimally invasive treatments to relieve cancer-associated pain in oncologic patients. Clinical applications, technical considerations, and current controversies are addressed. RECENT FINDINGS: The great variability in tumor subtype, location, and growth rates dictate the necessity for a tailored treatment approach. While opioids and radiotherapy may provide adequate relief for some patients, alternative minimally invasive procedures may augment theses more traditional treatments or even provide superior palliative relief. Recent image-guided percutaneous techniques applied to reduce cancer-associated pain and minimize opioid dependence include neurolysis, ablation, high intensity focused ultrasound, and bone consolidation. Each technique treats cancer pain in a unique method. Minimally invasive interventional radiology techniques can provide effective and lasting pain palliation for cancer patients through both indirect and direct effects. Selection among treatments techniques should be based upon an individually tailored approach, to include consideration of all treatment modalities.

The Role of Ablation in Cancer Pain Relief.

PURPOSE OF REVIEW: The purpose of this article is to describe the concepts of ablation techniques for pain relief in symptomatic oncologic patients. Controversies concerning techniques and products will be addressed. RECENT FINDINGS: Despite conventional pain palliative techniques, cancer patients often endorse unresolved somatic and neuropathic pain that can present as a great burden to quality of life. In non-operative patients, several techniques have been applied to minimize opioid dependence. While radiotherapy is often considered as a non-invasive option, percutaneous ablation has been advanced as a minimally-invasive alternative with clear procedural and outcome advantages. Similar to radiation therapy, percutaneous ablation techniques can act either upon nerve structures responsible for pain mediation signals (neurolysis) or directly upon the tumor to relieve tumor-mediated inflammation and decompress tumor compression of adjacent structures. Percutaneous ablation provides valuable neurolysis and tumor-directed pain palliative effects to be incorporated into clinical guidelines for pain reduction in oncologic patients. Selection among different ablation techniques should be based upon an individually tailored approach, to include consideration of all treatment modalities.