Effect of a Hispanic outreach program on referral and liver transplantation volume at a single center.

BACKGROUND: Although Hispanic patients have high rates of end-stage liver disease and liver cancer, for which liver transplantation (LT) offers the best long-term outcomes, they are less likely to receive LT. Studies of end-stage renal disease patients and kidney transplant candidates have shown that targeted, culturally relevant interventions can increase the likelihood of Hispanic patients receiving kidney transplant. However, similar interventions remain largely unstudied in potential LT candidates. METHODS: Referrals to a single center in Texas with a large Hispanic patient population were compared before (01/2018-12/2019) and after (7/2021-6/2023) the implementation of a targeted outreach program. Patient progress toward LT, reasons for ineligibility, and differences in insurance were examined between the two eras. RESULTS: A greater proportion of Hispanic patients were referred for LT after the implementation of the outreach program (23.2% vs 26.2%, p = 0.004). Comparing the pre-outreach era to the post-outreach era, more Hispanic patients achieved waitlisting status (61 vs 78, respectively) and received a LT (971 vs 82, respectively). However, the proportion of Hispanic patients undergoing LT dropped from 30.2% to 20.3%. In the post-outreach era, half of the Hispanic patients were unable to get LT for financial reasons (112, 50.5%). CONCLUSIONS: A targeted outreach program for Hispanic patients with end-stage liver disease effectively increased the total number of Hispanic LT referrals and recipients. However, many of the patients who were referred were ineligible for LT, most frequently for financial reasons. These results highlight the need for additional research into the most effective ways to ameliorate financial barriers to LT in this high-need community.

Surgical techniques for robotic right donor hepatectomy, part 2: robotic parenchymal transection and bile duct division.

Robotic surgery is emerging as a feasible minimally invasive approach for donor hepatectomy at specialized centers. The aim of this article is to systematically describe the surgical techniques for robotic parenchymal transection and bile duct division in right donor hepatectomy. The setup of the robotic arms, methods of parenchymal transection using robotic instruments, and right hepatic duct division with the aid of indocyanine green dye are detailed, along with the pearls and pitfalls of these two parts of the operation.

Surgical techniques for robotic right donor hepatectomy, part 1: robotic hilar dissection and right lobe mobilization.

Robotic surgery is emerging as a feasible minimally invasive approach for donor hepatectomy at specialized centers. The aim of this article is to systematically describe the surgical techniques for robotic hilar dissection and right lobe mobilization in right donor hepatectomy. The setup of the robotic arms, the dissection of inflow vessels and retrohepatic inferior vena cava, and the pearls and pitfalls of these two parts of the operation are detailed.

Transplant Oncology: An Emerging Discipline of Cancer Treatment.

Transplant oncology is an emerging concept of cancer treatment with a promising prospective outcome. The applications of oncology, transplant medicine, and surgery are the core of transplant oncology to improve patients' survival and quality of life. The main concept of transplant oncology is to radically cure cancer by removing the diseased organ and replacing it with a healthy one, aiming to improve the survival outcomes and quality of life of cancer patients. Subsequently, it seeks to expand the treatment options and research for hepatobiliary malignancies, which have seen significantly improved survival outcomes after the implementation of liver transplantation (LT). In the case of colorectal cancer (CRC) in the transplant setting, where the liver is the most common site of metastasis of patients who are considered to have unresectable disease, initial studies have shown improved survival for LT treatment compared to palliative therapy interventions. The indications of LT for hepatobiliary malignancies have been slowly expanded over the years beyond Milan criteria in a stepwise manner. However, the outcome improvements and overall patient survival are limited to the specifics of the setting and systematic intervention options. This review aims to illustrate the representative concepts and history of transplant oncology as an emerging discipline for the management of hepatobiliary malignancies, in addition to other emerging concepts, such as the uses of immunotherapy in a peri-transplant setting as well as the use of circulating tumor DNA (ctDNA) for surveillance post-transplantation.

Validation of a multidisciplinary virtual reality (VR) robotic surgical curriculum.

The objective is to identify whether trainees demonstrate improvement in a standardized knot-tying task as assessed by Global Evaluative Assessment of Robotic Skills (GEARS) score after completion of a virtual reality (VR) robotic curriculum. An IRB-exempt prospective study was conducted with surgical trainees from August 2021 to February 2023. Participants initially performed a baseline robotic suturing task in which they were instructed to tie interrupted square knots in 10 min. Participants then completed a virtual reality simulation curriculum involving 23 exercises until they achieved 90% proficiency on all tasks. Participants then repeated the suturing task. Pre- and post-curriculum suturing tasks were recorded, de-identified, and scored by expert graders using a GEARS score. Trainees from three academic centers were invited to participate. Medical students (MS1-MS3) and surgical residents from gynecology, urology, and general surgery were invited to participate. Twenty-five trainees completed the pre-curriculum suturing task, the VR curriculum, and the post-curriculum suturing task. Trainees demonstrated significant improvement in their post-test GEARS score by 2.43 points (p < 0.05) and were able to tie three additional knots within 10 min after completion of the curriculum (p < 0.05). Trainees also demonstrated a faster time to complete first knot (114 s improvement, p < 0.05) after completion of the curriculum. All participants agreed or strongly agreed that completion of the robotic curriculum helped them feel more comfortable using the robotic console, and improved their robotic surgical skills. Surgical trainees and medical students with limited prior robotic surgical experience demonstrated objective improvement after completion of a standardized VR curriculum.

Developing basic robotic skills using virtual reality simulation and automated assessment tools: a multidisciplinary robotic virtual reality-based curriculum using the Da Vinci Skills Simulator and tracking progress with the Intuitive Learning platform.

This study sought to develop basic robotic surgical skills among surgical trainees across multiple specialties using a VR-based curriculum and provided objective, on-demand, automated assessments using the Intuitive Learning platform. This curriculum was developed using the Da Vinci Skills Simulator and included 24 exercises. A pre-test and post-test were required for completion of the curriculum. Scores > 90 on individual exercises and the post-test were required for successful completion. The Intuitive learning platform provided automated performance metrics and tracked trainee progression. The curriculum was implemented and data collected over a 12-month period. 21 trainees completed the entire curriculum. Post-test scores were significantly higher than pre-test scores and trainees reported improvement in their robotic skills after curriculum completion. A comparison based on training level revealed that junior residents had significantly lower number of attempts per exercise, fewer penalties, and higher completion scores when compared to senior residents and fellows. Individual exercise analysis demonstrated that exercises, such as 'Three-Arm Relay' and 'Ring Rollercoaster', required the longest time and most attempts to achieve a passing score. The 'Energy Pedals' and 'Knot Tying' skills were the least-utilized skills addressed in the curriculum. Virtual reality-based curriculums using the Intuitive Learning platform can be standardized across multiple specialties allowing for the development of basic robotic skills, shared interdisciplinary surgical education, and provides powerful objective and automated performance metrics of trainees.

Does failure to perform prophylactic level VI node dissection leave persistent disease detectable by ultrasonography in patients with low-risk papillary carcinoma of the thyroid?

BACKGROUND: There is controversy regarding the need for prophylactic level VI central node dissection in patients with low-risk papillary thyroid carcinoma (PTC). This study focuses on the incidence of persistent level VI nodal disease in low-risk PTC without prophylactic central node dissection. METHODS: PTC was known at the time of thyroidectomy in 304 of the 761 patients who had initial thyroid surgery from 2001 to 2007. Therapeutic level VI node dissection was performed for suspicious or positive nodes. A prophylactic central node dissection was not done if suspicious nodes were not identified. All patients had a high-resolution ultrasonography, and almost all patients had a suppressed serum thyroglobulin level 4-6 months after thyroidectomy. RESULTS: A total of 112 of 304 patients (37%) had a therapeutic level VI node dissection. A prophylactic central node dissection was not performed in the remaining 192 patients. One hundred and sixty-one of the 192 patients (84%) were low risk. Biopsy-proven persistent disease was identified at the 4-6-month postoperative ultrasonography in only 3 of the 161 low-risk patients (1.8%). The suppressed serum thyroglobulin level was increased in these 3 patients and 2 additional patients. CONCLUSION: Failure to perform a prophylactic central node dissection in low-risk PTC resulted in both a very low incidence of persistent level VI nodal disease and elevated suppressed thyroglobulin 4-6 months after thyroidectomy.

Image-guided percutaneous thermal ablation for the palliative treatment of chest wall masses.

OBJECTIVES: To evaluate the palliative benefits of image-guided thermal ablation for the treatment of painful tumors affecting the chest wall. METHODS: Thirty-nine patients, median age 65 years, underwent percutaneous thermal ablation of 44 chest wall masses. Thirty-eight radiofrequency ablations (RFAs), 3 microwave ablations (MWAs), and 3 cryoablations were performed. Subjective pain reports at 1 week and 1 month postablation were scored from 0 to 4 based on a standard Likert pain relief scale, with 2 or higher representing clinically significant pain relief. RESULTS: Patients were followed for a median of 6 months. Overall, 31 of 44 procedures (70.5%) resulted in significant pain relief. Improvement followed 15 of 15 (100%) of ablations that were performed within 90 days of treatment with palliative external-beam radiation therapy (XRT), compared with 16 of 29 (55.2%) of the remaining procedures. Mean pain relief score at 1 month was 3.86 for the 15 combined procedures versus 1.96 for the 29 remaining procedures (P < 0.001). Local pain recurred after 5 of 31 positive responses (16.1%). Median survival was 11.2 +/- 2.3 months for patients with significant pain relief and 4.3 +/- 1.4 months for nonresponders (P < 0.001). Adverse events included a transient symptom "flare" (n = 5, 11.4%) and the exacerbation of a preexisting brachial plexopathy. CONCLUSIONS: Thermal ablation results in significant pain relief for the majority of patients and shows evidence of synergistic benefit when temporally combined with XRT. This minimally invasive technique appears to be a safe and durable alternative for the palliation of chest wall masses.

Pulmonary radiofrequency ablation: long-term safety and efficacy in 153 patients.

PURPOSE: To retrospectively evaluate long-term survival, local tumor progression, and complication rates for all percutaneous computed tomographic (CT)-guided lung tumor radiofrequency (RF) ablations performed at a tertiary care cancer hospital in patients who refused or who were not candidates for surgery. MATERIALS AND METHODS: This HIPAA-compliant study was approved by the institutional review board; informed consent was waived. Between 1998 and 2005, 153 consecutive patients (mean age, 68.5 years; range, 17-94 years) with 189 primary or metastatic medically inoperable lung cancers underwent percutaneous fluoroscopic CT-guided RF ablation. Clinical outcomes were compiled on the basis of review of medical records, imaging follow-up reports, and any biopsy-proved residual or recurrent disease (when available). Kaplan-Meier method was used to estimate overall survival and disease-free survival (progression) as a function of time since RF ablation. Comparisons between survival functions were performed by using the log-rank statistic; P < .05 was considered to indicate a significant difference. RESULTS: The overall 1-, 2-, 3-, 4-, and 5-year survival rates, respectively, for stage I non-small cell lung cancer were 78%, 57%, 36%, 27%, and 27%; rates for colorectal pulmonary metastasis were 87%, 78%, 57%, 57%, and 57%. The 1-, 2-, 3-, 4-, and 5-year local tumor progression-free rates, respectively, were 83%, 64%, 57%, 47%, and 47% for tumors 3 cm or smaller and 45%, 25%, 25%, 25%, and 25% for tumors larger than 3 cm. The difference between the survival curves associated with large (>3 cm) and small (< or =3 cm) tumors was significant (P < .002). The overall pneumothorax rate was 28.4% (52 of 183 ablation sessions), with a 9.8% (18 of 183 ablation sessions) chest tube insertion rate. The overall 30-day mortality rate was 3.9% (six of 153 patients), with a 2.6% (four of 153 patients) procedure-specific 30-day mortality rate. CONCLUSION: Lung RF ablation appears to be safe and linked with promising long-term survival and local tumor progression outcomes, especially given the patient population treated.

Hepatic tumor ablation with clustered microwave antennae: the US Phase II trial.

BACKGROUND: Thermal ablation techniques have become important treatment options for patients with unresectable hepatic malignancies. Microwave ablation (MWA) is a new thermal ablative technique that uses electromagnetic energy to produce coagulation necrosis. We report outcomes from the first clinical trial in the United States using MWA and a 915 MHz generator. PATIENTS AND METHODS: Patients with unresectable primary or metastatic liver cancer were enrolled in a multi-institutional trial from March 2004 through May 2006. Demographic information, diagnosis, treatment, and outcomes were documented. RESULTS: Eighty-seven patients underwent 94 ablation procedures for 224 hepatic tumors. Forty-two ablations (45%) were performed open, 7 (7%) laparoscopically, and 45 (48%) percutaneously. The average tumor size was 3.6 cm (range 0.5-9.0 cm). Single antenna ablation volumes were 10.0 ml (range 7.8-14.0 ml), and clustered antennae ablation volumes were 50.5 ml (range 21.1-146.5 ml). Outcome variables were measured with a mean follow-up of 19 months. Local recurrence at the ablation site occurred in 6 (2.7%) tumors, and regional recurrence occurred in 37 (43%) patients. With a mean follow-up of 19 months, 41 (47%) patients were alive with no evidence of disease. There were no procedure-related deaths. The overall mortality rate was 2.3%. CONCLUSIONS: Microwave ablation is a safe and effective technology for hepatic tumor ablation. In our study, clustered antennae resulted in larger ablation volumes. Further studies with histological confirmation are needed to verify clinical results.

Intraoperative triple antenna hepatic microwave ablation.

OBJECTIVE: Microwave ablation is emerging as a new treatment option for patients with unresectable hepatic malignancies. This two-center study shows the results of a phase 1 clinical trial of patients with known hepatic masses who underwent synchronous triple antenna microwave ablation before elective hepatic resection. SUBJECTS AND METHODS: Intraoperative microwave ablation was performed before hepatic resection. Hepatic lesions were targeted using real-time intraoperative sonography with three microwave antennas positioned in a triangular configuration. Microwave ablation was performed at 45 W for 10 minutes. Hepatic resection was then completed in the standard fashion. Gross specimens were sectioned and measured to determine tumor and ablation sizes. Representative areas were stained with H and E stain and vital histochemical nicotinamide adenine dinucleotide (NADH) stain. RESULTS: Ten patients with a mean age of 64 years (range, 48-79 years) were treated. Tumor histology included colorectal carcinoma metastases and hepatocellular carcinoma. The mean maximal tumor diameter was 4.4 cm (range, 2.0-5.7 cm). The mean maximal ablation diameter was 5.5 cm (range, 5.0-6.5 cm), while the average ablation zone volume was 50.8 cm3 (range, 30.3-65.5 cm3). Gross and microscopic examinations of areas after microwave ablation showed clear coagulation necrosis, even surrounding large hepatic vessels (> 3 mm in diameter). A marked thermallike effect was observed with maximal intensity closest to the antenna sites. NADH staining confirmed the uniform absence of viable tumor in the ablation zone. CONCLUSION: This study shows the feasibility of using multiple microwave antennas simultaneously in the treatment of liver tumors intraoperatively. Additional percutaneous studies are currently under way to investigate the safety and efficacy in treating nonsurgical candidates.

Percutaneous image-guided thermal ablation and radiation therapy: outcomes of combined treatment for 41 patients with inoperable stage I/II non-small-cell lung cancer.

PURPOSE: To evaluate the clinical outcomes in patients with early-stage non-small-cell lung cancer (NSCLC) after combined treatment with thermal ablation and radiation therapy (RT). MATERIALS AND METHODS: Forty-one patients with inoperable stage I/II NSCLC tumors underwent thermal ablation and RT at our institution between 1998 and 2005. Thirty-seven radiofrequency (RF) ablation procedures and four microwave ablation procedures were performed. Ablations were followed by standard-fraction external-beam RT within 90 days (n = 27) or postprocedural brachytherapy (n = 14). Survival and local recurrence were the primary endpoints evaluated by Kaplan-Meier analysis. RESULTS: The median follow-up was 19.5 months. The overall survival rates were 97.6% at 6 months, 86.8% at 1 year, 70.4% at 2 years, and 57.1% at 3 years. Patients with tumors smaller than 3 cm (n = 17) had an average survival time of 44.4 +/- 5.4 months (SE). Patients with tumors 3 cm or larger (n = 24) had an average survival time of 34.6 +/- 7.0 months (P = .08). Local recurrence occurred in 11.8% of tumors smaller than 3 cm after an average of 45.6 +/- 4.1 months and in 33.3% of the larger tumors after an average of 34.0 +/- 7.8 months (P = .03). Outcomes in the brachytherapy and RT groups did not differ significantly. Nine of 15 pneumothoraces required chest tube drainage (22.0%). CONCLUSIONS: Thermal ablation followed by RT for inoperable stage I/II NSCLC has a relatively low rate of complications that are easily managed. Combined therapy may result in an improved survival compared with either modality alone.

Percutaneous minimally invasive therapies in the treatment of bone tumors: thermal ablation.

Many percutaneous image-guided ablative techniques have been utilized in the treatment of bone cancers. These techniques are fast becoming a focus in the treatment of patients with both benign and malignant forms of bone cancer. This article will review the principles of radiofrequency ablation including its use in combination with other therapies, cryoablation, and microwave ablation in the treatment of osteoid osteomas and bone metastases.

Hepatocellular carcinoma: microwave ablation with multiple straight and loop antenna clusters--pilot comparison with pathologic findings.

The purpose of this study was to evaluate the clinical implementation of triangular and spherical designs for simultaneous multiple-antenna ablation of human hepatocellular carcinoma (HCC) with a recently engineered microwave coagulation system. Institutional review board approval and informed consent were obtained, and the study was compliant with HIPAA requirements. Nine patients (five men, four women; age range, 53-79 years; mean age, 66.2 years) with resectable HCC (diameter, 2.9-6.0 cm; mean, 4.2 cm) underwent intraoperative ultrasonography-guided tumor ablation followed by resection and pathologic examination. Standard single-straight (n = 2), triangular triple-straight (n = 4), and spherical triple-loop (n = 3) antenna configurations produced mean estimated coagulation volumes of 16.7, 51.7, and 54.3 cm(3), respectively, during a single concurrent 5-10-minute ablation cycle. The triple-loop configuration yielded the most uniformly round ablation shape. Simultaneous activation of multiple straight or loop antennae is a potentially promising technique for rapid and effective treatment of large HCCs.

Microwave ablation: principles and applications.

Microwave ablation is the most recent development in the field of tumor ablation. The technique allows for flexible approaches to treatment, including percutaneous, laparoscopic, and open surgical access. With imaging guidance, the tumor is localized, and a thin (14.5-gauge) microwave antenna is placed directly into the tumor. A microwave generator emits an electromagnetic wave through the exposed, noninsulated portion of the antenna. Electromagnetic microwaves agitate water molecules in the surrounding tissue, producing friction and heat, thus inducing cellular death via coagulation necrosis. The main advantages of microwave technology, when compared with existing thermoablative technologies, include consistently higher intratumoral temperatures, larger tumor ablation volumes, faster ablation times, and an improved convection profile. Microwave ablation has promising potential in the treatment of primary and secondary liver disease, primary and secondary lung malignancies, renal and adrenal tumors, and bone metastases. The technology is still in its infancy, and future developments and clinical implementation will help improve the care of patients with cancer.

Current role of image-guided ablative therapies in lung cancer.

Lung cancer is the leading cause of cancer-related mortality in the USA. Until recently, lung cancer treatment options (dependent upon the tumor grading and staging at presentation, and patient comorbidities) included surgical resection (lobar or sublobar), chemotherapy and external-beam radiation therapy. While these options are still viewed as the primary standard of care, newer minimally invasive percutaneous ablative techniques such as radiofrequency ablation, microwave ablation and cryoablation are currently being examined as treatment alternatives, especially in the setting of the nonsurgical candidate. This review will focus on these three distinct thermoablative techniques in the percutaneous setting of lung cancer treatment.