Can we apply the concept of sentinel lymph node in rectal cancer surgery?

INTRODUCTION: Colorectal cancer remains one of the most common causes of cancer-related mortality worldwide, and lymph node staging is crucial in the diagnostic and therapeutic process. Sentinel lymph nodes are the first involved in this process, but their validity in colorectal surgery has not yet been established. Following the emergence of new imaging instrumentation, some authors have attempted to propose different techniques for lymph node identification. However, a clear pattern of mesorectal lymph node distribution relative to the primary lesion site has yet to be defined. MATERIAL AND METHODS: Our analysis retrospectively reviewed suspicious mesorectal pathological lymph nodes on pre-operative magnetic resonance imaging (MRI) of rectal cancer patients, in order to assess the distribution patterns of possible tumour-related rectal lymph nodes. Mesorectal space was subdivided into quadrants and levels, and morphological features and distances from the lymph node to the primary rectal tumour were recorded. RESULTS: Two hundred and fifty-five mesorectal lymph nodes distributed among 60 patients were collected. Results show that in 92.1% of cases, nodes were distributed in the same mesorectal quadrant as the rectal primary tumour, and in 88.5% of cases, they were found at the same level as the rectal primary tumour. CONCLUSIONS: Although a clear node distribution pattern was not established, these results may suggest at least a lymphatic drainage preference lane, worthy of further investigation.

Identification of A0 minimum ablative margins for colorectal liver metastases: multicentre, retrospective study using deformable CT registration and artificial intelligence-based autosegmentation.

BACKGROUND: Several ablation confirmation software methods for minimum ablative margin assessment have recently been developed to improve local outcomes for patients undergoing thermal ablation of colorectal liver metastases. Previous assessments were limited to single institutions mostly at the place of development. The aim of this study was to validate the previously identified 5 mm minimum ablative margin (A0) using autosegmentation and biomechanical deformable image registration in a multi-institutional setting. METHODS: This was a multicentre, retrospective study including patients with colorectal liver metastases undergoing CT- or ultrasound-guided microwave or radiofrequency ablation during 2009-2022, reporting 3-year local disease progression (residual unablated tumour or local tumour progression) rates by minimum ablative margin across all institutions and identifying an intraprocedural contrast-enhanced CT-based minimum ablative margin associated with a 3-year local disease progression rate of less than 1%. RESULTS: A total of 400 ablated colorectal liver metastases (median diameter of 1.5 cm) in 243 patients (145 men; median age of 62 [interquartile range 54-70] years) were evaluated, with a median follow-up of 26 (interquartile range 17-40) months. A total of 119 (48.9%) patients with 186 (46.5%) colorectal liver metastases were from international institutions B, C, and D that were not involved in the software development. Three-year local disease progression rates for 0 mm, >0 and <5 mm, and 5 mm or larger minimum ablative margins were 79%, 15%, and 0% respectively for institution A (where the software was developed) and 34%, 19%, and 2% respectively for institutions B, C, and D combined. Local disease progression risk decreased to less than 1% with an intraprocedurally confirmed minimum ablative margin greater than 4.6 mm. CONCLUSION: A minimum ablative margin of 5 mm or larger demonstrates optimal local oncological outcomes. It is proposed that an intraprocedural minimum ablative margin of 5 mm or larger, confirmed using biomechanical deformable image registration, serves as the A0 for colorectal liver metastasis thermal ablation.

Combined transarterial chemoembolization and thermal ablation in candidates to liver transplantation with hepatocellular carcinoma: pathological findings and post-transplant outcome.

OBJECTIVES: Evaluating the pathological response and the survival outcomes of combined thermal ablation (TA) and transarterial chemoembolization (TACE) as a bridge or downstaging for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) > 3 cm. MATERIALS AND METHODS: A retrospective review encompassed 36 consecutive patients who underwent combined TA-TACE as bridging or downstaging before LT. Primary objectives included necrosis of the target lesion at explant pathology, post-LT overall survival (OS) and post-LT recurrence-free survival (RFS). For OS and RFS, a comparison with 170 patients subjected to TA alone for nodules <3 cm in size was also made. RESULTS: Out of the 36 patients, 63.9% underwent TA-TACE as bridging, while 36.1% required downstaging. The average node size was 4.25 cm. All cases were discussed in a multidisciplinary tumor board to assess the best treatment for each patient. Half received radiofrequency (RF), and the other half underwent microwave (MW). All nodes underwent drug-eluting beads (DEB) TACE with epirubicin. The mean necrosis percentage was 65.9% in the RF+TACE group and 83.3% in the MW+TACE group (p-value = 0.099). OS was 100% at 1 year, 100% at 3 years and 94.7% at 5 years. RFS was 97.2% at 1 year, 94.4% at 3 years and 90% at 5 years. Despite the different sizes of the lesions, OS and RFS did not show significant differences with the cohort of patients subjected to TA alone. CONCLUSIONS: The study highlights the effectiveness of combined TA-TACE for HCC>3 cm, particularly for bridging and downstaging to LT, achieving OS and RFS rates significantly exceeding 80% at 1, 3 and 5 years.

Acellular dermal matrix imaging features in breast reconstructive surgery: a pictorial review.

Acellular dermal matrices (ADMs) are biological engineered tissues, which may provide an immunologically inert scaffold in breast reconstruction. Since the literature on imaging features of ADMs is limited, radiologists must be aware of the common imaging appearances of ADM, to differentiate normal conformation from residual or recurrent disease. Our purpose is to review the current role of ADMs in implant-based breast reconstruction, describing the normal imaging findings at ultrasound, mammography, and MRI also considering the possible changes over time. In this pictorial essay, we reviewed imaging features of ADMs described in the literature and we reported our experience in patients who underwent reconstructive surgery with human or animal ADM for newly diagnosed breast cancer.

Optimisation of protection in the medical exposure of recurrent adult patients due to computed tomography procedures: development of recurrent exposures reference levels.

OBJECTIVES: To assess the incidence (1 year) and the cumulative incidence (3 years) of the condition of patients accruing cumulative effective doses (CED) of ≥ 100 mSv and their variability among different hospitals. To establish and validate a reference level for the CED in patients with recurrent exposures (RERL) and provide a RERL value. METHODS: Data of CT exposure was collected in 9 similar hospitals. The database included 294,222 patient*years who underwent 442,278 CT exams in 3 years. The incidence proportion of patients with CED ≥ 100 mSv in a given year (I100;1) and the 3-year cumulative incidence of patients with CED ≥ 100 mSv over 3 consecutive years (I100;3) were calculated and compared among different institutions. RESULTS: I100;1 ranged from a minimum of 0.1% to a maximum of 5.1%. The percentage of recurrent patients was quite uniform among centres ranging from 23 to 38%. The I100;3 ranged from a minimum of 1.1 to 11.4%. There was a strong positive correlation between the third quartile values of yearly CED and yearly incidence (r = 0.90; R2 = 0.81; p < 0.0001). RERL value in our study was found at 34.0 mSv. CONCLUSION: The management of patients with recurrent exposures is highly variable among hospitals leading to a 50-fold variation in I100;1 and to a tenfold variation in I100;3. RERL could be established and used by taking as a RERL quantity the CED and as a RERL value the 75th percentile of the third quartiles of the distribution of the yearly CED obtained by surveying different hospitals. CLINICAL RELEVANCE STATEMENT: This is the first ever multicentre study that quantifies recurrent exposures in terms of incidence and cumulative incidence of patients with CED ≥ 100 mSv. RERL establishment and use could benefit the optimisation of radioprotection of patients with recurrent exposures. KEY POINTS: This is the first multicentre study estimating yearly incidence and 3-year cumulative incidence of patients with cumulative effective doses ≥ 100 mSv. In this study, a 50-fold inter centre variation between the maximum (5.1%) and the minimum value (0.1%) of yearly incidence of patients with cumulative effective doses ≥ 100 mSv was reported. The range of the 3-year cumulative incidence extended from 1.1 to 11.4% (a tenfold variation) The third quartile of the yearly cumulative effective doses in a centre showed a strong positive correlation with the yearly incidence of patients with cumulative effective doses ≥ 100 mSv, with a potential of being used to set reference levels for recurrent exposures.

Role of integrated imaging in the diagnosis of an atypical and unresectable cardiac paraganglioma: a case report.

Background: Paragangliomas (PGLs) are rare neuroendocrine tumours that originate from extra-adrenal location. Cardiac PGLs can cause severe hypertension, palpitations, and lethal tachyarrhythmias. Diagnosis is based on measurement of plasma or urine metanephrines combined with conventional and nuclear imaging. Effective treatment is represented by surgical resection. We report a case of a 19-year-old patient with recurrent acute pericarditis; integrated imaging detected a large cardiac mass suggestive for PGL. Case summary: A 19-year-old male suffered pleuritic chest pain and fever for 4 days; electrocardiogram showed inferior ST elevation and transthoracic echocardiography a 2.2 cm pericardial effusion; these findings led to diagnose acute pericarditis. After a relapse of pericarditis, cardiac magnetic resonance and cardiac computed tomography (CCT) were performed, revealing a cardiac mass with radiological features of PGL. Blood and urine tests detected elevated levels of 3-methoxytyramine and chromogranin A. Gallium-68 positron emission tomography confirmed high metabolic activity of the mass. A negative 123-I-MIBG scintigraphy ruled out the possibility of radiometabolic treatment. A second CCT excluded the chance of surgical resection, due to intra-lesional course of the left anterior descending coronary artery. The young patient was referred to a different centre to achieve reduction of the mass, in order to potentially resect it afterwards. Discussion: Cardiac PGLs are rare tumours with significant morbidity related to norepinephrine secretion. In this case, without typical clinical manifestations and with no chance of surgical resection, integrated imaging played a central role in the differential diagnosis between PGL and other cardiac masses, providing both static and dynamic characterization.

Cardiac magnetic resonance of hypertrophic heart phenotype: A review.

Hypertrophic heart phenotype is characterized by an abnormal left ventricular (LV) thickening. A hypertrophic phenotype can develop as adaptive response in many different conditions such as aortic stenosis, hypertension, athletic training, infiltrative heart muscle diseases, storage disorders and metabolic disorders. Hypertrophic cardiomyopathy (HCM) is the most frequent primary cardiomyopathy (CMP) and a genetical cause of cardiac hypertrophy. It requires the exclusion of any other cause of LV hypertrophy. Cardiac magnetic resonance (CMR) is a comprehensive imaging technique that allows a detailed evaluation of myocardial diseases. It provides reproducible measurements and myocardial tissue characterization. In clinical practice CMR is increasingly used to confirm the presence of ventricular hypertrophy, to detect the underlying cause of the phenotype and more recently as an efficient prognostic tool. This article aims to provide a detailed overview of the applications of CMR in the setting of hypertrophic heart phenotype and its role in the diagnostic workflow of such condition.

Effectiveness and Safety of Different Vascular Closure Devices: Multicentre Prospective Observational study.

AIM: The aim of this prospective, multicentre, observational study was to compare the efficacy and safety of balloon-based and non-balloon-based vascular closure devices (VCDs). MATERIALS AND METHODS: From March 2021 to May 2022, 2373 participants from 10 different centres were enrolled. Among them, 1672 patients with 5-7 Fr accesses were selected. Successful haemostasis, failure and safety were evaluated. Successful haemostasis was defined as the possibility to obtain complete haemostasis with the use of VCDs, without any complication. Failure management was defined as the need of manual compression. Safety was defined as the rate of complications. Cases of haematomas/pseudoaneurysms (PSA) and artero-venous fistula (AVF) were collected. RESULTS: VCDs mechanism of action is statistically significant associated with the outcome. Non-balloon-based VCDs demonstrated a statistically significant better outcome: successful haemostasis was obtained in 96.5% vs. 85.9%, of cases when compared to balloon occluders (p < 0.001). The incidence of AVF was statistically more frequent using non-balloon occluders devices (1.57% vs 0%, p: 0.007). No significant statistical difference was found in comparing haematoma and PSA occurrence. Thrombocytopenia, coagulation deficit, BMI, diabetes mellitus and anti-coagulation were demonstrated to be independent predictors of failure management. CONCLUSION: Our study suggests a better outcome with the same complication rate, except that for AVF incidence for non-balloon collagen plug device if compared to balloon occluders vascular closure devices.

All-in-one diagnostic and therapeutic precision thoracic surgery using a hybrid operating theatre: the triple-marking technique.

BACKGROUND: The minimally invasive management of sub-centimetric and often sub-solid lung lesions is quite challenging for thoracic surgeons. As a matter of fact, thoracoscopic wedge resection can often require conversion to thoracotomy when pulmonary lesions cannot be visually identified. Hybrid operating rooms (ORs) can serve as a helpful tool in a multidisciplinary setting, providing real-time lesion imaging and targeting, allowing preoperative or intraoperative percutaneous placement of different lesions targeting techniques to help locate non-palpable lung nodules during video-assisted thoracic surgery. The aim of the study is to assess whether the lung nodule marking using methylene blue, indocyanine green, and gold seeds - the "triple-marking technique" - in the hybrid OR is effective in helping locate non-visible or palpable nodules. METHODS: We conducted a retrospective study on 19 patients with non-palpable lung lesions requiring VATS wedge resection and underwent lesional targeting in the hybrid operating room with different marking systems, including gold seeds placement, methylene blue, or indocyanine green. Lesions were considered non-palpable due to sizing, radiological subsolid aspect, or location and then identified using intraoperative CT scans, also allowing to elaborate needle trajectory. The intraoperative diagnosis was obtained in all of the patients guiding the type of surgery performed. RESULTS: The radio-opaque gold seed marker was used in all of the patients except for two cases that developed intraprocedural pneumothoraces with no major consequences. In these patients, the nodule marking using dyes was still performed and successful in allowing to locate the lesion. Methylene blue and indocyanine green were always used in combination during the dye-targeting phase. Methylene blue appeared to be non-visible in two patients. The indocyanine green was correctly visualized in every patient. We observed the gold seed dislocation in two patients. We were able to identify the lung lesion in all the patients correctly. No conversion was needed. No allergic reactions were observed due to dye administration, and no prophylaxis was performed prior to lesional marking. The lung lesions were visually identified in 100% of the patients thanks to at least one marking technique. CONCLUSIONS: Our experience confirms that the hybrid operating room can represent a suitable tool in helping locate hard-to-find lung lesions in planned VATS resections. Using different techniques, a multiple marking approach seems advisable to maximize the lung lesions detecting rate by direct vision, therefore reducing the VATS conversion rate.

Prevalence of Cortisol Cosecretion in Patients With Primary Aldosteronism: Role of Metanephrine in Adrenal Vein Sampling.

CONTEXT: Adrenal venous sampling (AVS) is the gold standard procedure for subtype diagnosis in patients with primary aldosteronism (PA). Cortisol is usually adopted for the normalization of aldosterone levels in peripheral and adrenal samples. However, asymmetrical cortisol secretion can potentially affect the lateralization index, leading to subtype misdiagnosis. OBJECTIVE: We aimed to assess the prevalence of asymmetrical cortisol secretion in patients undergoing AVS and whether variations in adrenal vein cortisol might influence AVS interpretations. We then evaluated the use of metanephrines for the normalization of aldosterone levels for lateralization index. METHODS: We retrospectively included 101 patients with PA who underwent AVS: 49 patients underwent unstimulated AVS, while 52 patients underwent both unstimulated and cosyntropin-stimulated AVS. Eighty-eight patients had bilateral successful AVS according to metanephrine ratio. We assessed the prevalence of asymmetrical cortisol secretion through the cortisol to metanephrine (C/M) lateralization index (LI). We then evaluated whether the use of aldosterone to metanephrine (A/M) LI can improve the diagnostic accuracy of AVS compared with aldosterone to cortisol (A/C) LI. RESULTS: Asymmetrical cortisol secretion is present in 18% of patients with PA. Diagnosis with A/M LI and A/C LI is discordant in 14% of patients: 9% had a diagnosis of unilateral PA with A/M LI instead of bilateral PA with A/C LI and 5% had a diagnosis of bilateral PA with A/M LI instead of unilateral PA. CONCLUSION: The assessment of metanephrine levels in AVS is useful for the determination of selectivity and lateralization, allowing an accurate diagnosis, especially in patients with asymmetrical cortisol secretion.

The Role of Immediate Post-Procedural Cone-Beam Computed Tomography (CBCT) in Predicting the Early Radiologic Response of Hepatocellular Carcinoma (HCC) Nodules to Drug-Eluting Bead Transarterial Chemoembolization (DEB-TACE).

The purpose of this study was to evaluate the efficacy of unenhanced cone-beam computed tomography (CBCT) performed at the end of drug-eluting bead transarterial chemoembolization (DEB-TACE) in predicting HCC nodules' early radiologic response to treatment, assessed using mRECIST criteria with a 30−60 day four-phase contrast-enhanced CT follow-up. Fifty-nine patients (81 lesions) subjected to DEB-TACE as exclusive treatment for HCC lesions (naive/relapse) between February 2020 and October 2021 were prospectively enrolled. In a post-interventional unenhanced CBCT procedure, two experienced radiologists evaluated for each lesion the overall intensity of the contrast media deposit, the homogeneity of the enhancement, and the presence of smooth and complete margins. The univariate analysis found that lesions with complete response (CR+) had a significantly higher incidence of clear and complete margins than CR− lesions (76.9% vs. 17.2%, p = 0.003) and a higher intensity score (67.3% vs. 27.6%, p = 0.0009). A Dmax <30 mm was significantly more common among CR+ than CR− lesions (92.3% vs. 69%, p = 0.01). These features were confirmed as significant predictors for CR+ by multivariate binary logistic regression. The homogeneity of the enhancement did not affect the DEB-TACE outcome. Post-interventional unenhanced CBCT is effective in predicting early radiological response to DEB-TACE, since the presence of an intense contrast media deposit with clear and complete margins in treated HCC lesions is associated with CR.

Role of gadoxetic acid-enhanced liver magnetic resonance imaging in the evaluation of hepatocellular carcinoma after locoregional treatment.

Locoregional treatments, as alternatives to surgery, play a key role in the management of hepatocellular carcinoma (HCC). Liver magnetic resonance imaging (MRI) enables a multiparametric assessment, going beyond the traditional dynamic computed tomography approach. Moreover, the use of hepatobiliary agents can improve diagnostic accuracy and are becoming important in the diagnosis and follow-up of HCC. However, the main challenge is to quickly identify classical responses to loco-regional treatments in order to determine the most suitable management strategy for each patient. The aim of this review is to provide a summary of the most common and uncommon liver MRI findings in patients who underwent loco-regional treatments for HCC, with a special focus on ablative therapies (radiofrequency, microwaves and cryoablation), trans-arterial chemoembolization, trans-arterial radio-embolization and stereotactic ablative radiotherapy techniques, considering the usefulness of gadoxetate disodium (Gd-EOB-DTPA) contrast agent.

Cost-effectiveness analysis of personalised versus standard dosimetry for selective internal radiation therapy with TheraSphere in patients with hepatocellular carcinoma.

Aims: To perform a cost-effectiveness analysis (CEA) comparing personalised dosimetry with standard dosimetry in the context of selective internal radiation therapy (SIRT) with TheraSphere for the management of adult patients with locally advanced hepatocellular carcinoma (HCC) from the Italian Healthcare Service perspective. Materials and methods: A partition survival model was developed to project costs and the quality-adjusted life years (QALYs) over a lifetime horizon. Clinical inputs were retrieved from a published randomised controlled trial. Health resource utilisation inputs were extracted from the questionnaires administered to clinicians in three oncology centres in Italy, respectively. Cost parameters were based on Italian official tariffs. Results: Over a lifetime horizon, the model estimated the average QALYs of 1.292 and 0.578, respectively, for patients undergoing personalised and standard dosimetry approaches. The estimated mean costs per patient were €23,487 and €19,877, respectively. The incremental cost-utility ratio (ICUR) of personalised versus standard dosimetry approaches was €5,056/QALY. Conclusions: Personalised dosimetry may be considered a cost-effective option compared to standard dosimetry for patients undergoing SIRT for HCC in Italy. These findings provide evidence for clinicians and payers on the value of personalised dosimetry as a treatment option for patients with HCC.

A randomised controlled trial of digital breast tomosynthesis vs digital mammography as primary screening tests: Screening results over subsequent episodes of the Proteus Donna study.

Proteus Donna is a randomised controlled trial aimed at prospectively evaluating screening with digital breast tomosynthesis (DBT), including interval cancer detection (ICD) and cancer detection (CD) in the analysis as a cumulative measure over subsequent screening episodes. Consenting women aged 46 to 68 attending the regional Breast Screening Service were randomly assigned to conventional digital mammography (DM, control arm) or DBT in addition to DM (DBT, study arm). At the subsequent round all participants underwent DM. Thirty-six months follow-up allowed for the identification of cancers detected in the subsequent screening and interscreening interval. Relative risk (RR) and 95% confidence interval (95% CI) were computed. Cumulative CD and Nelson-Aalen incidence were analysed over the follow-up period. Between 31 December 2014 and 31 December 2017, 43 022 women were randomised to DM and 30 844 to DBT. At baseline, CD was significantly higher (RR: 1.44, 95% CI: 1.21-1.71) in the study arm. ICD did not differ significantly between the two arms (RR: 0.92, 95% CI: 0.62-1.35). At subsequent screening with DM, the CD was lower (nearly significant) in the study arm (RR: 0.83, 95% CI: 0.65-1.06). Over the follow-up period, the cumulative CD (comprehensive of ICD) was slightly higher in the study arm (RR: 1.15, 95% CI: 1.01-1.31). The Nelson-Aalen cumulative incidence over time remained significantly higher in the study arm for approximately 24 months. Benign lesions detection was higher in the study arm at baseline and lower at subsequent tests. Outcomes are consistent with a lead time gain of DBT compared to DM, with an increase in false positives and moderate overdiagnosis.

mEPE-score: a comprehensive grading system for predicting pathologic extraprostatic extension of prostate cancer at multiparametric magnetic resonance imaging.

OBJECTIVE: To investigate the diagnostic accuracy of the PI-RADS v2.1 multiparametric magnetic resonance imaging (mpMRI) features in predicting extraprostatic extension (mEPE) of prostate cancer (PCa), as well as to develop and validate a comprehensive mpMRI-derived score (mEPE-score). METHODS: We retrospectively reviewed all consecutive patients admitted to two institutions for radical prostatectomy for PCa with available records of mpMRI performed between January 2015 and December 2020. Data from one institution was used for investigating diagnostic performance of each mEPE feature using radical prostatectomy specimens as benchmark. The results were implemented in a mEPE-score as follows: no mEPE features: 1; capsular abutment: 2; irregular or spiculated margin: 3; bulging prostatic contour, or asymmetry of the neurovascular bundles, or tumor-capsule interface > 1.0 cm: 4; ≥ 2 of the previous three parameters or measurable extraprostatic disease: 5. The performance of mEPE features was evaluated using the five diagnostic parameters and ROC curve analysis. RESULTS: Two-hundred patients were enrolled at site 1 and 76 at site 2. mEPE features had poor sensitivities ranging from 0.08 (0.00-0.15) to 0.71 (0.59-0.83), whereas specificity ranged from 0.68 (0.58-0.79) to 1.00. mEPE-score showed excellent discriminating ability (AUC > 0.8) and sensitivity = 0.82 and specificity = 0.77 with a threshold of 3. mEPE-score had AUC comparable to ESUR-score (p = 0.59 internal validation; p = 0.82 external validation), higher than or comparable to mEPE-grade (p = 0.04 internal validation; p = 0.58 external validation), and higher than early-and-late-EPE (p < 0.0001 internal and external validation). There were no significant differences between readers having different expertise with EPE-score (p = 0.32) or mEPE-grade (p = 0.45), but there were significant differences for ESUR-score (p = 0.02) and early-versus-late-EPE (p = 0.03). CONCLUSIONS: The individual mEPE features have low sensitivity and high specificity. The use of mEPE-score allows for consistent and reliable assessment for pathologic EPE. KEY POINTS: • Individual PI-RADS v2.1 mpMRI features had poor sensitivities ranging from 0.08 (0.00-0.15) to 0.71 (0.59-0.83), whereas Sp ranged from 0.68 (0.58-0.79) to 1.00. • mEPE-score is an all-inclusive score for the assessment of pEPE with excellent discriminating ability (i.e., AUC > 0.8) and Se = 0.82, Sp = 0.77, PPV = 0.74, and NPV = 0.84 with a threshold of 3. • The diagnostic performance of the expert reader and beginner reader with pEPE-score was comparable (p = 0.32).

Multi-institutional analysis of outcomes for thermosphere microwave ablation treatment of colorectal liver metastases: the SMAC study.

OBJECTIVES: Oligometastatic colorectal cancer benefits of locoregional treatments but data concerning microwave ablation (MWA) are limited and interactions with systemic therapy are still debated. The aim of this study is to evaluate safety and effectiveness of Thermosphere™ MWA (T-MWA) of colorectal liver metastases (CLM) and factors affecting local tumor progression-free survival (LTPFS). METHODS: In this multi-institutional retrospective study (January 2015-September 2019), patients who underwent T-MWA for CLM were enrolled. Complications according to SIR classification were collected, primary efficacy and LTP were calculated. Analyzed variables included CLM size at diagnosis and at ablation, CLM number, ablation margins, intra-segment progression, chemotherapy before ablation (CBA), variations in size (ΔSDIA-ABL), and velocity of size variation (VDIA-ABL) between CLM diagnosis and ablation. Uni/multivariate analyses were performed using mixed effects Cox model to account for the hierarchical structure of data, patient/lesions. RESULTS: One hundred thirty-two patients with 213 CLM were evaluated. Complications were reported in 6/150 procedures (4%); no biliary complications occurred. Primary efficacy was achieved in 204/213 CLM (95.7%). LTP occurred in 58/204 CLM (28.4%). Six-, twelve-, and eighteen-month LTPFS were 88.2%, 75.8%, and 69.9%, respectively. At multivariate analysis, CLM size at ablation (p = 0.00045), CLM number (p = 0.046), ablation margin < 5 mm (p = 0.0035), and intra-segment progression (p < 0.0001) were statistically significant for LTPFS. ΔSDIA-ABL (p = 0.63) and VDIA-ABL (p = 0.38) did not affect LTPFS. Ablation margins in the chemo-naïve group were larger than those in the CBA group (p < 0.0001). CONCLUSION: T-MWA is a safe and effective technology with adequate LTPFS rates. Intra-segment progression is significantly linked to LTPFS. CBA does not affect LTPFS. Anticipating ablation before chemotherapy may take the advantages of adequate tumor size with correct ablation margin planning. KEY POINTS: • Thermosphere™-Microwave ablation is a safe and effective treatment for colorectal liver metastases with no registered biliary complications in more than 200 ablations. • Metastases size at time of ablation, intra-segment progression, and minimal ablation margin < 5 mm were found statistically significant for local tumor progression-free survival. • Chemotherapy before ablation modifies kinetics growth of the lesions but deteriorates ablation margins and does not significantly impact local tumor progression-free survival.

Impact of computed-tomography defined sarcopenia on outcomes of older adults undergoing transcatheter aortic valve implantation.

BACKGROUND: The adoption of Computed tomography (CT)-defined sarcopenia to risk stratify transcatheter aortic valve implantation (TAVI) candidates remains limited by a lack of both standardized definition and evidence of independent value over currently adopted mortality prediction tools. METHODS: 391 consecutive TAVI patients with pre-procedural CT scan were included (81 â€‹± â€‹6 years, 57.5% male, STS-PROM score 4.4 â€‹± â€‹3.6%) and abdominal muscle retrospectively quantified. The two definitions of radiologic sarcopenia previously adopted in TAVI studies were compared (psoas muscle area [PMA] at the L4 vertebra level: "PMA-sarcopenia"; indexed skeletal muscle area at the L3 vertebra level: "SMI-sarcopenia"). The primary endpoint was longer available-term all-cause mortality. Secondary endpoints were Valve Academic Research Consortium-2-defined in-hospital and 30-day outcomes. RESULTS: SMI- and PMA-sarcopenia were present in 192 (49.1%) and 117 (29.9%) patients, respectively. After a median of 24 (12-30) months follow-up, 83 (21.2%) patients died. PMA-(adj-HR 1.81, 95%CI 1.12-2.93, p â€‹= â€‹0.015), but not SMI-sarcopenia (adj-HR 1.23, 95%CI 0.76-2.00, p â€‹= â€‹0.391), was associated with all-cause mortality independently of age, sex and in-study outcome predictors (atrial fibrillation, hemoglobin, history of peripheral artery disease, cancer and subcutaneous adipose tissue). PMA-defined sarcopenia provided additive prognostic value over current post-TAVI mortality risk estimators including STS-PROM (p â€‹= â€‹0.001), Euroscore II (p â€‹= â€‹0.025), Charlson index (p â€‹= â€‹0.025) and TAVI2-score (p â€‹= â€‹0.020). Device success, early safety, clinical efficacy and 30-day all-cause death were unaffected by sarcopenia status regardless of definition. CONCLUSIONS: PMA-sarcopenia (but not SMI-sarcopenia) is predictive of 2 year mortality among TAVI patients. The prognostic information provided by PMA-sarcopenia is independent of the tools currently adopted to predict post-TAVI mortality in clinical practice.

Ultra-Low-Dose Whole-Body Computed Tomography Protocol Optimization for Patients With Plasma Cell Disorders: Diagnostic Accuracy and Effective Dose Analysis From a Reference Center.

BACKGROUND: The whole-body low-dose CT (WBLDCT) is the first-choice imaging technique in patients with suspected plasma cell disorder to assess the presence of osteolytic lesions. We investigated the performances of an optimized protocol, evaluating diagnostic accuracy and effective patient dose reduction using a latest generation scanner. METHODS AND MATERIALS: Retrospective study on 212 patients with plasma cell disorders performed on a 256-row CT scanner. First, WBLDCT examinations were performed using a reference protocol with acquisition parameters obtained from literature. A phantom study was performed for protocol optimization for subsequent exams to minimize dose while maintaining optimal diagnostic accuracy. Images were analyzed by three readers to evaluate image quality and to detect lesions. Effective doses (E) were evaluated for each patient considering the patient dimensions and the tube current modulation. RESULTS: A similar, very good image quality was observed for both protocols by all readers with a good agreement at repeated measures ANOVA test (p>0.05). An excellent inter-rater agreement for lesion detection was achieved obtaining high values of Fleiss' kappa for all the districts considered (p<0.001). The optimized protocol resulted in a 56% reduction of median DLP (151) mGycm, interquartile range (IQR) 128-188 mGycm vs. 345 mGycm, IQR 302-408 mGycm), of 60% of CTDIvol (2.2 mGy, IQR 1.9-2.7 mGy vs. 0.9 mGy, IQR 0.8-1.2 mGy). The median E value was about 2.6 mSv (IQR 1.7-3.5 mSv) for standard protocol and about 1.5 mSv (IQR 1.4-1.7 mSv) for the optimized one. Dose reduction was statistically significant with p<0.001. CONCLUSIONS: Protocol optimization makes ultra-low-dose WBLDCT feasible on latest generation CT scanners for patients with plasma cell disorders with effective doses inferior to conventional skeletal survey while maintaining excellent image quality and diagnostic accuracy. Dose reduction is crucial in such patients, as they are likely to undergo multiple whole-body CT scans during follow-up.

Optimizing Loco Regional Management of Oligometastatic Colorectal Cancer: Technical Aspects and Biomarkers, Two Sides of the Same Coin.

Colorectal cancer (CRC) is the third most common cancer worldwide and has a high rate of metastatic disease which is the main cause of CRC-related death. Oligometastatic disease is a clinical condition recently included in ESMO guidelines that can benefit from a more aggressive locoregional approach. This review focuses the attention on colorectal liver metastases (CRLM) and highlights recommendations and therapeutic locoregional strategies drawn from the current literature and consensus conferences. The different percutaneous therapies (radiofrequency ablation, microwave ablation, irreversible electroporation) as well as trans-arterial approaches (chemoembolization and radioembolization) are discussed. Ablation margins, the choice of the imaging guidance as well as characteristics of the different ablation techniques and other technical aspects are analyzed. A specific attention is then paid to the increasing role of biomarkers (in particular molecular profiling) and their role in the selection of the proper treatment for the right patient. In conclusion, in this review an up-to-date state of the art of the application of locoregional treatments on CRLM is provided, highlighting both technical aspects and the role of biomarkers, two sides of the same coin.

The value of a combined radiological-surgical approach in allowing curative resection of a locally advanced type IIIa Klatskin tumor.

We report the case of a 53-year-old patient subjected to percutaneous embolization of right and middle hepatic veins to induce liver segments 2-3 hypertrophy before extended right hepatic resection for a locally advanced type IIIa perihilar cholangiocarcinoma. Hepatic vein embolization (HVE) was performed 3 weeks after surgical recanalization of left portal vein (severely narrowed at its origin due to tumor infiltration) interposing an internal jugular vein graft between main and distal left portal vein. Nine days after HVE, future liver remnant volume increased from 395 to 501 cc, i.e. 25.1% of standardized total liver volume, allowing to perform a radical right hepatic trisectionectomy plus caudatectomy. He was discharged home on postoperative day 15th after an uneventful postoperative course, with no sign of posthepatectomy liver failure.