Anatomical Quantitative Volumetric Evaluation of Liver Segments in Hepatocellular Carcinoma Patients Treated with Selective Internal Radiation Therapy: Key Parameters Influencing Untreated Liver Hypertrophy.

Background: Factors affecting morphological changes in the liver following selective internal radiation therapy (SIRT) are unclear, and the available literature focuses on non-anatomical volumetric assessment techniques in a lobar treatment setting. This study aimed to investigate quantitative changes in the liver post-SIRT using an anatomical volumetric approach in hepatocellular carcinoma (HCC) patients with different levels of treatment selectivity and evaluate the parameters affecting those changes. This retrospective, single-institution, IRB-approved study included 88 HCC patients. Whole liver, liver segments, tumor burden, and spleen volumes were quantified on MRI at baseline and 3/6/12 months post-SIRT using a segmentation-based 3D software relying on liver vascular anatomy. Treatment characteristics, longitudinal clinical/laboratory, and imaging data were analyzed. The Student's t-test and Wilcoxon test evaluated volumetric parameters evolution. Spearman correlation was used to assess the association between variables. Uni/multivariate analyses investigated factors influencing untreated liver volume (uLV) increase. Results: Most patients were cirrhotic (92%) men (86%) with Child-Pugh A (84%). Absolute and relative uLV kept increasing at 3/6/12 months post-SIRT vs. baseline (all, p ≤ 0.005) and was maximal during the first 6 months. Absolute uLV increase was greater in Child-Pugh A5/A6 vs. ≥B7 at 3 months (A5, p = 0.004; A6, p = 0.007) and 6 months (A5, p = 0.072; A6, p = 0.031) vs. baseline. When the Child-Pugh class worsened at 3 or 6 months post-SIRT, uLV did not change significantly, whereas it increased at 3/6/12 months vs. baseline (all p ≤ 0.015) when liver function remained stable. The Child-Pugh score was inversely correlated with absolute and relative uLV increase at 3 months (rho = -0.21, p = 0.047; rho = -0.229, p = 0.048). In multivariate analysis, uLV increase was influenced at 3 months by younger age (p = 0.013), administered 90Y activity (p = 0.003), and baseline spleen volume (p = 0.023). At 6 months, uLV increase was impacted by younger age (p = 0.006), whereas treatment with glass microspheres (vs. resin) demonstrated a clear trend towards better hypertrophy (f = 3.833, p = 0.058). The amount (percentage) of treated liver strongly impacted the relative uLV increase at 3/6/12 months (all f ≥ 8.407, p ≤ 0.01). Conclusion: Liver function (preserved baseline and stable post-SIRT) favored uLV hypertrophy. Younger patients, smaller baseline spleen volume, higher administered 90Y activity, and a larger amount of treated liver were associated with a higher degree of untreated liver hypertrophy. These factors should be considered in surgical candidates undergoing neoadjuvant SIRT.

99mTc-macroaggregated albumin SPECT/CT predictive dosimetry and dose-response relationship in uveal melanoma liver metastases treated with first-line selective internal radiation therapy.

First-line selective internal radiation therapy (SIRT) showed promising outcomes in patients with uveal melanoma liver metastases (UMLM). Patient survival depends on liver's disease control. SIRT planning is essential and little is known about dosimetry. We investigated whether 99mTc-MAA-SPECT/CT dosimetry could predict absorbed doses (AD) evaluated on 90Y-PET/CT and assess the dose-response relationship in UMLM patients treated with first-line SIRT. This IRB-approved, single-center, retrospective analysis (prospectively collected cohort) included 12 patients (median age 63y, range 43-82). Patients underwent MRI/CT, 18F-FDG-PET/CT before and 3-6 months post-SIRT, and 90Y-PET/CT immediately post-SIRT. Thirty-two target lesions were included. AD estimates in tumor and non-tumor liver were obtained from 99mTc-MAA-SPECT/CT and post-SIRT 90Y-PET/CT, and assessed with Lin's concordance correlation coefficients (ρc and Cb), Pearson's coefficient correlation (ρ), and Bland-Altman analyses (mean difference ± standard deviation; 95% limits-of-agreement (LOA)). Influence of tumor characteristics and microsphere type on AD was analyzed. Tumor response was assessed according to size-based, enhancement-based and metabolic response criteria. Mean target lesion AD was 349 Gy (range 46-1586 Gy). Concordance between 99mTc-MAA-SPECT/CT and 90Y-PET/CT tumor dosimetry improved upon dose correction for the recovery coefficient (RC) (ρ = 0.725, ρc = 0.703, Cb = 0.969) with good agreement (mean difference: - 4.93 ± 218.3 Gy, 95%LOA: - 432.8-422.9). Without RC correction, concordance was better for resin microspheres (ρ = 0.85, ρc = 0.998, Cb = 0.849) and agreement was very good between predictive 99mTc-MAA-SPECT/CT and 90Y-PET/CT dosimetry (mean difference: - 4.05 ± 55.9 Gy; 95%LOA: - 113.7-105.6). After RC correction, 99mTc-MAA-SPECT/CT dosimetry overestimated AD (- 70.9 ± 158.9 Gy; 95%LOA: - 382.3-240.6). For glass microspheres, concordance markedly improved with RC correction (ρ = 0.790, ρc = 0.713, Cb = 0.903 vs without correction: ρ = 0.395, ρc = 0.244, Cb = 0.617) and 99mTc-MAA-SPECT/CT dosimetry underestimated AD (148.9 ± 267.5 Gy; 95%LOA: - 375.4-673.2). For non-tumor liver, concordance was good between 99mTc-MAA-SPECT/CT and 90Y-PET/CT dosimetry (ρ = 0.942, ρc = 0.852, Cb = 0.904). 99mTc-MAA-SPECT/CT slightly overestimated liver AD for resin (3.4 ± 3.4 Gy) and glass (11.5 ± 13.9 Gy) microspheres. Tumor AD was not correlated with baseline or post-SIRT lesion characteristics and no dose-response threshold could be identified. 99mTc-MAA-SPECT/CT dosimetry provides good estimates of AD to tumor and non-tumor liver in UMLM patients treated with first-line SIRT.

Case Report: Tyrosine Kinase Inhibitors Induced Lymphadenopathy in Desmoid Tumor Patients.

Tyrosine kinase inhibitors (TKIs) are nowadays a valuable treatment of desmoid tumors, a rare mesenchymal neoplasm. Although many side effects of imatinib and pazopanib, commonly or rarely occurring, have been described, reactional lymphadenopathy has not yet been reported. In this publication, we report two cases of patients with desmoid tumors, treated with pazopanib and imatinib, who developed reactional lymphadenopathy. As this side effect is presented as a newly formed mass, it can result in new diagnostic questions and added imaging tests and can even lead to discontinuation of the treatment. This report may help the clinicians facing similar problems adopt a "watch and wait" approach.

CIRSE Standards of Practice on Thermal Ablation of Bone Tumours.

BACKGROUND: Percutaneous thermal ablation is an effective, minimally invasive means of treating a variety of focal benign and malignant osseous lesions. To determine the role of ablation in individual cases, multidisciplinary team (MDT) discussion is required to assess the suitability and feasibility of a thermal ablative approach, to select the most appropriate technique and to set the goals of treatment i.e. curative or palliative. PURPOSE: This document will presume the indication for treatment is clear and approved by the MDT and will define the standards required for the performance of each modality. CIRSE Standards of Practice documents are not intended to impose a standard of clinical patient care, but recommend a reasonable approach to, and best practices for, the performance of thermal ablation of bone tumours. METHODS: The writing group was established by the CIRSE Standards of Practice Committee and consisted of five clinicians with internationally recognised expertise in thermal ablation of bone tumours. The writing group reviewed the existing literature on thermal ablation of bone tumours, performing a pragmatic evidence search using PubMed to search for publications in English and relating to human subjects from 2009 to 2019. Selected studies published in 2020 and 2021 during the course of writing these standards were subsequently included. The final recommendations were formulated through consensus. RESULTS: Recommendations were produced for the performance of thermal ablation of bone tumours taking into account the biologic behaviour of the tumour and the therapeutic intent of the procedure. Recommendations are provided based on lesion characteristics and thermal modality, for the use of tissue monitoring and protection, and for the appropriately timed application of adjunctive procedures such as osseus consolidation and transarterial embolisation. RESULTS: Percutaneous thermal ablation has an established role in the successful management of bone lesions, with both curative and palliative intent. This Standards of Practice document provides up-to-date recommendations for the safe performance of thermal ablation of bone tumours.

Image-guided marking techniques in interventional radiology: A review of current evidence.

Precise marking of lesions using image-guided techniques is essential, as imprecise targeting of a tumor can result in either insufficient excision/treatment with an increased risk of recurrence, or excessive removal of healthy tissue. Most frequent indications include localization of nonpalpable lesions before surgical resection (i.e., hook-wire localization of pulmonary nodules before video-assisted thoracoscopy) and definite marking of liver metastasis before neoadjuvant therapy. Other indications include marking of hepatocellular carcinomas that are not visible on ultrasound and unenhanced computed tomography before thermal ablation, of bone lesions before surgical excision, and of different visceral tumors before stereotactic radiotherapy. This review presents the different existing indications, assesses their usefulness, gives systematic details on the technique and lastly analyzes the current literature with emphasis on results and complications.

CIRSE Clinical Practice Manual.

BACKGROUND: Interventional radiology (IR) has come a long way to a nowadays UEMS-CESMA endorsed clinical specialty. Over the last decades IR became an essential part of modern medicine, delivering minimally invasive patient-focused care. PURPOSE: To provide principles for delivering high quality of care in IR. METHODS: Systematic description of clinical skills, principles of practice, organizational standards and infrastructure needed for the provision of professional IR services. RESULTS: There are IR procedures for almost all body parts and organs, covering a broad range of medical conditions. In many cases IR procedures are the mainstay of therapy, e.g. in the treatment of hepatocellular carcinoma. In parallel the specialty moved from the delivery of a procedure towards taking care for a patient's condition with the interventional radiologists taking ultimate responsibility for the patient's outcomes. CONCLUSIONS: The evolution from a technical specialty to a clinical specialty goes along with changing demands on how clinical care in IR is provided. The CIRSE Clinical Practice Manual provides interventional radiologist with a starting point for developing his or her IR practice as a clinician.

Cryoablation of Extra-Abdominal Desmoid Tumors: A Single-Center Experience with Literature Review.

Cryoablation (CA) has gained popularity in the treatment of benign and malignant musculoskeletal tumors. While extra-abdominal desmoid (EAD) tumors are not malignant, they remain challenging to treat because of their high local recurrence rate. We reviewed all EAD tumors treated with CA at our institution between November 2012 and March 2020. Fourteen procedures were performed on nine females and one male (mean age, 33 ± 18 years) as either first-line (n = 4) or salvage therapy (n = 6) with curative intent (n = 8) or tumor debulking (n = 2). Mean tumor size was 63.6 cm3 (range, 3.4-169 cm3). Contrast-enhanced MRI was performed before treatment and at 3-, 6-, and 12-month follow-up. Treatment outcome was based on the change in enhanced tumor volume (ET-V). For curatively treated patients, the mean ET-V change was -97 ± 7%, -44 ± 143%, and +103 ± 312% at 3, 6, and 12 months, respectively. For debulking patients, the mean ET-V change was -98 ± 4%, +149 ± 364%, and +192 ± 353% at 3, 6, and 12 months, respectively. During a mean follow-up of 53.7 months (range, 12-83 months), one grade III and one grade IV complication were noted. We found CA to be safe and well tolerated in patients with EAD.

Transarterial Radioembolization for the Treatment of Advanced Hepatocellular Carcinoma Invading the Right Atrium.

Hepatocellular carcinoma (HCC) has the tendency to invade the portal and/or hepatic venous system. The invasion of the right atrium is uncommonly observed and constitutes a treatment challenge. We report the case of a patient with HCC invading the right atrium treated with 90Yttrium-transarterial radioembolization (90Y-TARE). Following the treatment, organizing pneumonia secondary to nivolumab occurred, raising the question of an interaction between 90Y-TARE and nivolumab.

Salvage Lymph-Node Percutaneous Cryoablation: Safety Profile and Oncologic Outcomes.

Purpose To evaluate the technical feasibility and safety of percutaneous cryoablation (CA) for the treatment of single/oligometastatic lymph-node (LN) relapse in different anatomic regions. MATERIALS AND METHODS: This is a retrospective study of all patients who underwent percutaneous CA of LN metastases (May 2014-April 2019). RESULTS: Eighteen patients with a total of 27 LNs were treated with CT-guided CA (Galil Medical, Israel). One patient was excluded since no follow-up was available. The mean LN diameter was 11 mm (range 4-28 mm). Thirteen patients had a history of previous treatment for locoregional lymphadenopathy. In 21 LNs, a supplementary thermal insulation-displacement technique was used (hydrodissection = 12; carbodissection = 6; both = 3). According to the RECIST criteria, 8 LNs had a complete response, 8 stable disease, 8 partial response and 1 progressive disease. In the subgroup of patients with prostate cancer relapse, the mean PSA level before treatment was 5.5 ngr/ml (range 0.6-36 ngr/ml) and reduced to 0.32 (range 0-1.1 ngr/ml) and 0.3 (range 0-0.6 ngr/ml) at 3- and 6-month follow-up, respectively. Six patients presented distant tumor deposits on follow-up that were further treated with systemic (5 patients: hormone/chemo/immunotherapy) and local therapies (1 patient: CA of bone oligometastatic disease). No major complication was noted. Two patients with obturator LN presented transient obturator nerve paresis. Mean follow-up was 15 months (range 1-56 months). CONCLUSION: In this series of patients, we have shown that metastatic LNs can be safely treated with image-guided CA. Caution should be paid, and additional measures should be taken when treating LNs near thermal-sensible structures.

Electromagnetic navigation system combined with High-Frequency-Jet-Ventilation for CT-guided hepatic ablation of small US-Undetectable and difficult to access lesions.

Objectives: To report the feasibility and efficacy of percutaneous ablation of small hepatic malignant tumors that are invisible on ultrasound and inaccessible using in-plane CT guidance, using a combination of high-frequency jet-ventilation (HFJV) and electromagnetic (EM) needle tracking. Methods: This study reviewed 27 percutaneous ablations of small hepatic tumors (<2 cm) performed using EM navigation-based probe placement and HFJV. All lesions were invisible on ultrasound and difficult to reach on CT requiring a double-oblique approach. The primary outcome was technical efficacy, defined as complete lesion coverage, and evaluated on contrast enhanced MRI after 3 and 6 months. Needle placement accuracy, the number of control CT acquisitions, procedure time, complications and radiation doses were assessed. Results: Twenty-one patients with 27 treated lesions (14 hepatocellular carcinomas and 13 metastases) were included in this study. Mean tumor size was 12 ± 5.7 mm. Thirty-three percent of the lesions were located on the hepatic dome. Complete ablation was obtained in 100% at the 3- and 6-month MRI follow-up. The ablation probe was correctly placed on the first pass in 96%, with a mean path-to-tumor angle of 7 ± 4 degrees and a mean tip-to-tumor distance of 22 ± 19mm. A readjustment for additional overlapping application resulted in complete treatment in 4 patients. Needle placement took a mean 23 ± 12 min with mean radiation doses of 558 mGy*cm. No major complications were reported. Conclusion: Percutaneous liver ablation of lesions that cannot be seen on US and requiring out-of-plane CT access can be successfully and safely treated using electromagnetic-based navigation and jet-ventilation.

Percutaneous MR-guided whole-gland prostate cancer cryoablation: safety considerations and oncologic results in 30 consecutive patients.

OBJECTIVE: To assess the safety and oncological efficacy of percutaneous MR-guided whole-gland prostate cancer (PCa) cryoablation (CA). METHODS AND MATERIALS: Between July 2009 and January 2018, 30 patients (mean age 72.9 ± 5.13 years) with histologically proven, organ-confined (≤ T2cN0M0), predominantly low/intermediate-risk PCa (median Gleason score 7; mean prostate specific antigen 6.05 ± 3.74 ng ml-1 ) underwent MR-guided whole-gland CA. Patients were selected on the basis of prior pelvic radiotherapy (n = 16; 12 for previous PCa), or contra indication/refusal of surgery or radiotherapy. Complications, local progression-free survival (LPFS) and overall survival (OS) were retrospectively investigated. RESULTS: Eighteen [60%] patients reported procedure-related complications: 5/18 [28%] needed surgical/interventional treatments and 13 [72%] conservative or pharmacological treatment. Eleven [73%] complications were noted in the first 15 patients and 7 [47%] in the last 15 patients (p = 0.26). Mean nadir prostate specific antigen was 0.24 ± 1.5 ng ml-1 (mean follow-up 3.8 years; range: 2 - 2915 days). Seven [23%] patients developed histologically proven local progression (mean time to recurrence 775 days, range: 172 - 2014). Mean clinical follow-up was 3.8 years (range 1-2915 days). LPFS was 92.0, 75.7 and 69.4 % at 1-, 3- and 5 year follow-up, respectively. For patients in salvage treatment, LPFS was 100%, 75%, and 75% at 1-, 3- and 5 year follow-up. OS was 100%, 94.4 and 88.5 % at 1-, 3- and 5 year follow-up respectively, with no patients dying from PCa. CONCLUSION: Whole-gland PCa CA offers good oncological efficacy, particularly in post-radiotherapy cases. Although the complication rate is significant, the majority is minor and is managed with conservative or pharmacologic management. ADVANCES IN KNOWLEDGE: MRI-guided whole-gland prostate cancer cryoablation offers good oncological efficacy, particularly in post-radiotherapy cases with a contained complication rate.

Current role of interventional radiology in the management of visceral and bone metastases from thyroid cancer.

The metastatic disease from thyroid cancer represents a complex clinical scenario, which mandates a case-based multi-disciplinary approach in tertiary referral centers. Direct localised treatments such as minimally invasive interventional radiology procedures can play a vital role in providing a timely palliative or curative treatment in accordance with the patients' clinical status. In this narrative review, we present the current status of interventional radiology treatments for the management of thyroid cancer distant metastases.

How to Perform a Routine Cryoablation Under MRI Guidance.

In the last decade, the spectrum of interventional magnetic resonance imaging (MRI)-guided procedures, including percutaneous ablation, has substantially grown, and among the available MRI-compatible ablative techniques, cryoablation is progressively gaining a predominant position.The aim of the present narrative review is to discuss the technical requirements necessary to perform a percutaneous MRI-guided cryoablation in a closed-bore machine; to highlight the relative advantages and drawbacks; and to briefly summarize the results available in the literature.

Adrenal Biopsy under Wide-Bore MR Imaging Guidance.

Twenty-four magnetic resonance (MR) imaging-guided percutaneous adrenal biopsies performed between April 2009 and October 2016 were reviewed retrospectively. Epidemiologic, procedural, and histopathologic data were retrospectively collected. Mean size of tumors was 4.3 cm (range, 1.5-16.0 cm). Mean procedure time was 49 min (range, 24-95 min). Mean needle angulation was 27.7° (range, 0°-60°). Mean depth was 9.6 cm (range, 5.8-13.7 cm). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MR imaging-guided biopsy were 95.5%, 100%, 100%, 66.7%, and 95.8%, respectively. There were no immediate or delayed complications. MR imaging guidance seems safe and accurate to target adrenal-gland masses.

Protection of the Proximal Articular Cartilage During Percutaneous Thermal Ablation of Acetabular Metastasis Using Temperature Monitoring.

OBJECTIVE: To review our initial experience in acetabular cartilage protection from thermal injury with temperature monitoring during percutaneous image-guided tumor thermal ablation. MATERIALS AND METHODS: Between June 2015 and December 2016, three consecutive oncologic patients (mean age 58 years; range 48-67 years) with acetabular bone metastasis underwent percutaneous image-guided thermal ablation procedures along with hip joint cartilage thermal monitoring. Due to the close proximity of the metastatic lesion to the acetabular articular cartilage, a thermosensor device was placed under CT and fluoroscopic guidance near the acetabular roof and next to the ablation zone in order to monitor the local temperature around the articular cartilage. Stand-alone thermal ablation (n = 1) and combined thermal ablation with cementoplasty (n = 2) were performed to optimize local palliation or disease control. Clinical and radiological outcomes at follow-up were assessed. RESULTS: Three acetabular metastatic lesions were treated with thermal ablation, and temperature monitoring of the acetabular articular cartilage was conducted during the ablation procedure. Mean size of lesions was 1.6 cm (range 1.5-2 cm). Technical success was achieved in all cases (100%) without any immediate complications. No hip cartilage damage occurred clinically and radiologically. Good palliation and local disease control were achieved in two cases, and in the other case, there was local recurrence and distant progression of hip metastatic disease after 7 months of follow-up. CONCLUSION: Temperature monitoring of the articular cartilage during percutaneous image-guided thermal ablation appears technically feasible with good short-term efficacy in a complex patient subset. Further studies are warranted to confirm these promising initial results.

Safety Considerations and Local Tumor Control Following Percutaneous Image-Guided Cryoablation of T1b Renal Tumors.

OBJECTIVE: To retrospectively assess the safety and oncological efficacy of percutaneous image-guided cryoablation (CA) of T1b (> 4 cm/< 7 cm) renal tumors. MATERIALS AND METHODS: Institutional electronic records were retrospectively reviewed to identify the patients who had undergone percutaneous CA of T1b renal tumors between 2008 and 2016. CA was proposed by a multidisciplinary tumor board for cases with poor renal function or a single kidney; unsuitable for surgical resection; or genetic syndromes predisposing to multiple hereditary renal tumors. Patients' demographics, procedural and follow-up data were accurately collected and analyzed. RESULTS: Twenty-seven consecutive patients (12 females, 15 males; mean age 72.3 ± 14.3 years) were included. Mean tumor diameter was 47.9 ± 6.3 mm. MRI guidance was used in 6/27 cases (22.2%) and CT guidance in the remaining 21/27 (77.8%) cases. Hydro- and/or carbo-dissections were necessary in 21/27 cases (77.8%). Complications graded ≥ II were reported in three (11.1%) patients. Technical success and technical efficacy were 100 and 87.5%, respectively. Local tumor control (LTC) evaluated at imaging follow-up ≥ 6 months was 82.6, 72.3 and 60.3% at 12-, 24- and 36-month follow-up, respectively. One patient passed away 3 months after CA due to the metastatic evolution of the primary kidney cancer. CONCLUSION: Percutaneous CA of T1b renal tumors is safe and satisfactory rates of LTC are expected at the early follow-ups. Further studies are needed to confirm the long-term efficacy of this procedure.

PET/CT-guided interventions: Indications, advantages, disadvantages and the state of the art.

Positron emission tomography/computed tomography (PET/CT) represents an emerging imaging guidance modality that has been applied to successfully guide percutaneous procedures such as biopsies and tumour ablations. The aim of the present narrative review is to report the indications, advantages and disadvantages of PET/CT-guided procedures in the field of interventional oncology and to briefly describe the experience gained with this new emerging technique while performing biopsies and tumor ablations.

Trans-rectal Ultrasound-Guided Autologous Blood Injection in the Interprostatorectal Space Prior to Percutaneous MRI-Guided Cryoablation of the Prostate.

OBJECTIVE: To report a novel technique of ultrasound-guided injection of autologous blood in the interprostatorectal space, in an attempt to facilitate ablative prostatic procedures by widening durably the space between the rectum and the prostate. MATERIALS AND METHODS: Between April and November 2016, four consecutive patients underwent the haemoprotection injection technique. For each patient, we recorded the time to perform the technique, the amount of injected blood, the achieved distances between the rectum and the prostate post-injection at fixed defined points (apex, middle, and base of prostate at the midline, left, and right sides of the gland), the extension of the ice ball outside the prostate capsule at those fixed points, and whether any residual blood was present on 1-month follow-up MRI. RESULTS: Mean time to perform haemoprotection injection was 54 min, with an average blood volume of 103 cc. Mean distance achieved at the apex, middle, and base of the prostate, respectively, was 12, 13, and 16 mm in the midline; 8, 10, and 13 mm on the left side; and 9, 10, and 13 mm on the right side. The mean extension distance of the ice ball beyond the capsule was 4, 6, and 6 mm in the midline; 4, 5, and 6 mm on the left side; and 1, 3, and 3 mm on the right side. No residual blood was present on 1-month follow-up MRI in all patients. No rectal fistula occurred. CONCLUSION: Haemoprotection may create a safe and effective virtual space between the prostate and rectum.

Percutaneous image-guided screws meditated osteosynthesis of impeding and pathological/insufficiency fractures of the femoral neck in non-surgical cancer patients.

AIM: To present percutaneous image-guided screw-mediated osteosynthesis (PIGSMO) for fixation of impending fractures (ImF) and non-displaced/mildly displaced pathological/insufficient fractures (PF/InF) of the femoral neck in non-surgical cancer patients. MATERIALS AND METHODS: This is a double-centre single-arm observational study. Retrospective review of electronic records identified all oncologic patients who had undergone femoral neck PIGSMO. Inclusion criteria were: non-displaced or mildly displaced PF/InF, and ImF (Mirels' score ≥8); life expectancy ≥1 month; unsuitability for surgical treatment due to sub-optimal clinical fitness, refusal of consent, or unacceptable delay to systemic therapy. RESULTS: Eleven patients were treated (mean age 63.7±13.5 years) due to ImF (63.6%, mean Mirels' score 10.1), PF (27.3%) or post-radiation InF (9.1%) under CT/fluoroscopy- (36.4%) or CBCT- (63.6%) guidance. Thirty-two screws were implanted and cement injection was added in 36.4% cases. Technical success was 90.9%. No procedure related complications were noted. At 1-month clinical follow-up (pain/walking impairment), 63.6% and 27.3% patients reported significant and mild improvement, respectively. Imaging follow-up (available in 63.6% cases) showed no signs of secondary fractures, neither of screws loosening at mean 2.8 months. Five patients (45.5%) died after PIGSMO (mean time interval 3.6 months). CONCLUSIONS: PIGSMO is technically feasible and safe in cancer patients with limited life expectancy; it offers good short-term results. Further prospective studies are required to corroborate mid- and to prove long-term efficacy of the technique.

Performance of a New Blunt-Tip Coaxial Needle for Percutaneous Biopsy and Drainage of "Hard-To-Reach" Targets.

AIM: To present a new blunt-tip coaxial needle (SoftGuard) applied to access "hard-to-reach" targets undergoing percutaneous image-guided biopsy or drainage. MATERIALS AND METHODS: All consecutive patients presenting between August and December 2016 with "hard-to-reach" (<10 mm from a critical nearby structure such as vessels, nerves, bowel or adjacent parenchymal organs) solid lesions requiring biopsy (group A) or abscesses requiring drainage for sepsis (group B) were prospectively included. The individual features of each patient and lesion as well as technical and clinical data were collected and analysed. RESULTS: Twenty-six patients (18 males, 8 females, mean age 59.81 ± 17.53 years) were enrolled in group A and nine (6 males, 3 females, mean age 58.33 ± 13.8 years) in group B. Technical success was achieved in 92.3% of cases from group A and 100% of cases from group B. Five (19.2%) minor complications were noted in group A (four small self-limiting pneumothoraces and one small self-limiting peri-pancreatic haematoma). There were no complications in group B. Histological results in group A accounted for 95% sensitivity, 100% specificity and 95.2% diagnostic accuracy. In group B, mean post-operative C-reactive protein was 41 ± 48.3 mg/L in comparison with 155 ± 117.5 mg/L at baseline (P = 0.004). CONCLUSIONS: The SoftGuard blunt-tip needle is a safe and effective tool when applied as a coaxial working cannula for percutaneous biopsy or drainage of "hard-to-reach" targets.