Implications of radiofrequency ablation in patients undergoing thyroid surgery for benign disease in the United States.

BACKGROUND: Radiofrequency ablation is an alternative strategy for the management of benign thyroid conditions. We analyzed the proportion of patients who underwent thyroid surgery for benign conditions who would be potentially eligible for radiofrequency ablation. METHODS: We identified patients who underwent thyroid surgery from 2015 to 2019 at the study institution for Bethesda II cytopathology or toxic adenoma. Patients were considered potentially eligible for radiofrequency ablation if they had a dominant nodule >2 cm with or without compression symptoms, a dominant nodule <2 cm with compression symptoms, or a toxic adenoma. RESULTS: Of 411 patients in total, 284 (69.1%) would be eligible to consider thyroid radiofrequency ablation. In the radiofrequency ablation-eligible group, 20 (7.0%) experienced voice change after surgery, and 2 (0.7%) were dissatisfied or concerned about their scar. In the radiofrequency ablation-eligible group, 70 patients (24.6%) had malignancy diagnosed by final pathology, and 23 patients (8.1%) had cancers that were equal to or larger than 1 cm in size. CONCLUSION: Many patients who undergo surgery for benign thyroid disease could be considered for radiofrequency ablation as an alternative treatment modality. Given the rate of occult malignancy, optimal evaluation of nondominant nodules before radiofrequency ablation and long-term thyroid surveillance for patients who undergo radiofrequency ablation should be further studied.

Resection or ablation versus transarterial therapy for Child-Pugh A patients with a single small hepatocellular carcinoma.

ABSTRACT: Data from a direct comparison of the long-term survival outcomes of surgical resection (SR) or radiofrequency ablation (RFA) versus transarterial therapy in Child-Turcotte-Pugh (CTP)-class A patients with a single small T1/T2 stage hepatocellular carcinoma (HCC) (≤3 cm) are still lacking. This study retrospectively compared the therapeutic outcomes of these treatment types for CTP-A patients with a single small HCC.Using a nationwide Korean registry, we identified 2314 CTP-A patients with SR (n = 722), RFA (n = 731), or transarterial therapy (n = 861) for a single (≤3 cm) T1/T2 stage HCC from 2008 to 2014. The posttreatment overall survival (OS) of transarterial therapy with either SR or RFA were compared using the Inverse Probability of treatment Weighting (IPW). The median follow-up period was 50 months (range 1-107 months).After IPW, the cumulative OS rates after SR or RFA were significantly higher than those after transarterial therapy in all subjects (all P values < .05). The OS rates after SR or RFA were better than those after transarterial therapy in patients with the hepatitis B or C virus (all P values < .05), and in patients aged <65 years (all P values < .05). The cumulative OSs between RFA and transarterial therapy were statistically comparable in patients with a 2 to 3 cm HCC and aged ≥65 years, respectively. For all subjects, the weighted Cox proportional hazards model using IPW provided the adjusted hazard ratios (95% confidence interval) for the OS after SR versus transarterial therapy and after RFA versus transarterial therapy of 0.42 (0.30-0.60) (P < .001) and 0.78 (0.61-0.99) (P = .044), respectively.In CTP-A patients with a single (≤3 cm) T1/T2 HCC, SR or RFA provides a better OS than transarterial therapy, regardless of the HCC etiology (hepatitis B virus or hepatitis C virus), especially in patients with HCC of <2 cm and aged <65 years.

Optimal application of stereotactic body radiotherapy and radiofrequency ablation treatment for different multifocal hepatocellular carcinoma lesions in patients with Barcelona Clinic Liver Cancer stage A4-B1: a pilot study.

BACKGROUND: In clinical practice, many hepatocellular carcinoma (HCC) patients in Barcelona Clinical Liver Cancer (BCLC) stage A4-B1 cannot receive the curative treatments of liver transplantation, resection, and radiofrequency ablation (RFA), which are the recommended options according to liver cancer guidelines. Our aim is to study the feasibility of RFA and stereotactic body radiotherapy (SBRT) as a curative treatment for different multifocal HCCs in BCLC stage A4-B1 patients. METHODS: From September 2014 to August 2019, 39 multifocal HCC lesions (median diameter: 16.6 mm) from 15 patients (median age: 73 years) were retrospectively selected. Among them, 23 were treated by RFA and the other 16 by SBRT because of predictable insufficiency and/or risk related to RFA performance. The indicators for evaluating this novel therapy were the tumor response, prognosis (recurrence and survival), and adverse effects (deterioration of laboratory test values and severe complications). RESULTS: The median follow-up duration was 31.3 months (range: 15.1-71.9 months). The total patients with a one-year complete response, stable disease, or disease progression were 11, 1, and 3, respectively. In total, 8 and 2 patients had confronted intrahepatic or local recurrence, respectively. The one-year progression-free survival rate and local control rate were 80% (12/15 patients) and 97.4% (38/39 lesions), respectively. The median time to progression was 20.1 (2.8-45.1) months. The one- and two-year survival rates were 100 and 88.9%, respectively. In up to five months' observation, no patient showed severe complications. Seven, four, and two patients had slight changes in their white blood cells, platelet count, or albumin-bilirubin grade, respectively. CONCLUSIONS: For patients with BCLC stage A4-B1, RFA and SBRT treatment for different multifocal HCCs may be a potential option because of the favorable prognosis and safety. However, before its application in clinical practice, prospective, controlled, large-scale studies are needed to further confirm our conclusions.

Long-term Outcomes of Transcatheter Arterial Chemoembolization Combined With Radiofrequency Ablation as an Initial Treatment for Early-Stage Hepatocellular Carcinoma.

Importance: The long-term outcomes of transcatheter arterial chemoembolization (TACE) combined with radiofrequency ablation (RFA) are not determined. Objective: To report the long-term outcomes of TACE-RFA. Design, Setting, and Participants: This cohort study analyzed long-term follow-up data from a phase 3 randomized clinical trial of adults with early HCC conducted from October 2006 to June 2009. Participants were randomly assigned to the TACE-RFA group or the RFA group in a 1:1 ratio and followed up approximately 6 years after the trial was closed. Data analysis was performed March 2020. Exposure: In the TACE-RFA group, TACE was performed first, and RFA was done 2 weeks later. Main Outcomes and Measures: Overall survival (OS) and recurrence-free survival (RFS). Results: Of 189 patients who were included (mean [SD] age, 54.3 [12.0] years; 146 [77.2%] men), 94 and 95 patients were assigned to the TACE-RFA group and RFA group, respectively, with their baseline characteristics well matched. Three patients in each group were lost to follow-up. The 5-year and 7-year OS rates for the TACE-RFA group vs the RFA group were 52.0% and 36.4% vs 43.2% and 19.4%, respectively (hazard ratio [HR], 0.55; 95% CI, 0.39-0.78; P = .001). The 5-year and 7-year RFS rates for the TACE-RFA group vs the RFA group were 41.4% and 34.5% vs 27.4% and 18.1%, respectively (HR, 0.66; 95% CI, 0.49-0.89; P = .007). On subgroup analysis comparing patients who had tumors larger than 3 cm with those who had tumors 3 cm or smaller, the OS and RFS survival rates in the TACE-RFA group (HR, 3.20; 95% CI, 1.91-5.35, P < .001) were significantly better than those in the RFA group (HR, 2.03; 95% CI, 1.30-3.17; P = .002). Conclusions and Relevance: In this cohort study, combined RFA and TACE was associated with better survival than RFA alone on long-term follow-up. Patients with tumors 3 cm or smaller did not benefit as well as patients with tumors larger than 3 cm from the combined treatment.

The predictive value of vessels encapsulating tumor clusters in treatment optimization for recurrent early-stage hepatocellular carcinoma.

BACKGROUND: The predictive value of vessels encapsulating tumor clusters (VETC) in recurrent early-stage hepatocellular carcinoma (HCC) remains unclear. Therefore, the aim of the present study was to investigate the prognostic significance of VETC in patients with recurrent early-stage HCC after repeat hepatic resection (RHR) or radiofrequency ablation (RFA). METHODS: From December 2005 to December 2016, 138 patients receiving RHR and 188 patients receiving RFA were recruited. VETC was evaluated by immunohistochemical staining for CD34. The survival outcomes of patients with VETC pattern or not were investigated. RESULTS: There was no significant difference between the RHR and RFA groups in disease-free survival (DFS) or overall survival (OS) as determined by the univariate analysis of the whole cohort. In the subgroup analysis of the VETC-positive cohort, the patients in the RHR group showed a longer median DFS time in contrast to those in the RFA group (15.0 vs. 5.0 months, p = 0.001). Similarly, the patients in the RHR group showed a longer median OS time in contrast to those in the RFA group (39.5 vs. 19 months, p = 0.001). In the VETC-negative cohort, no significant differences in DFS and OS rates between the RHR and RFA groups were observed (p > 0.05). CONCLUSIONS: The results of our study suggested that RHR was relatively safe and superior to RFA in improving survival outcomes for recurrent early-stage HCC after initial hepatectomy. Furthermore, the VETC pattern may represent a reliable marker for selecting HCC patients who may benefit from RHR.

Multimodal therapy for hepatocellular carcinoma: the role of surgery.

OBJECTIVE: Liver cancer is one of the widest spread malignancies in the world and its incidence is still on the rise. The surgical resection of liver cancer has become a widely performed procedure with considerably improved outcomes, low mortality rate, transfusions, and post-op bed stay. MATERIALS AND METHODS: Our goal with this paper was to conduct a narrative review of the literature in regard to the surgical treatment of hepatocellular carcinoma (HCC). RESULTS: There are various modalities of treatment for the HCC, e.g., hepatic resection, LT, or radiofrequency ablation (RFA) - the selection of a specific treatment regimen plays a decisive role in the survival rate of the patient and this, in turn, is guided by factors like size and distribution of lesion and the stage of malignancy. A more efficient patient selection for each treatment increases the survival rate of the patients in each subgroup. CONCLUSIONS: Surgical procedures play a crucial role in treatment of hepatocellular carcinoma as part of a multimodal therapy.

The learning curve of laparoscopic ablation of liver tumors: A technically demanding procedure requiring dedicated training.

BACKGROUND: Laparoscopic ablation (LA) of liver tumors is an increasingly performed procedure. However, LA is technically demanding, with inherent difficulties making LA more complex than percutaneous and open surgery ablations. This study aimed to characterize the learning curve (LC) of LAs. METHODS: All consecutive LAs of malignant liver tumors performed with curative intent by a single surgeon were identified from a prospective database. A risk-adjusted cumulative summative (RA-CUSUM) analysis was used for evaluating the LC of LAs. Incomplete ablation (IA) was the outcomes measure. Performance trends were analyzed using broken-line modeling. RESULTS: From June 2007 to February 2018, 241 lesions underwent LA during 151 procedures. RA-CUSUM analysis demonstrated an LC of 93 LAs (p < 0.001), with an IA rate decreasing from 12.9% to 4.7% (p = 0.027). Lesions in the posterosuperior segment and those in cirrhotic livers showed an LC of 34 and 45 tumor ablations, respectively (p=<0.001 each). Open ablations performed during the same period showed steady outcomes, indicating already acquired proficiency. CONCLUSION: Completion of a steep LC is needed to gain proficiency in LAs. Dedicated training should be warranted to novices to smooth the LC and decrease LA failures.

A Propensity Score Matching Study Between Microwave Ablation and Radiofrequency Ablation in Terms of Safety and Efficacy for Benign Thyroid Nodules Treatment.

Background: Large benign thyroid nodules often lead to cosmetic problems and compression on trachea. Thermal ablation is an effective method for benign thyroid nodules treatment. Among all the thermal ablation techniques, microwave and radiofrequency are frequently used energy sources. However, treatment outcomes of the two ablation types have not been compared in detail. Therefore, we conducted this study aiming for comparing the safety and efficacy of the two ablation techniques in benign thyroid nodules treatment. Methods: Information was retrospectively collected from patients with benign thyroid nodules, who received radiofrequency ablation or microwave ablation between January 1, 2018, and December 31, 2019, in a main hospital in South China. Patients were divided into microwave ablation group and radiofrequency ablation group according to the techniques applied. A propensity score matching was performed to balance the baseline indexes between the two groups. We also recorded and analyzed the operative variables including operative duration, intraoperative blood loss, hospitalization time, and overall costs. Postoperative quality of life, volume reduction rates, and complication rates were routinely evaluated during the follow-up by asking patients to fulfil questionnaires at the 1st, 3rd, 6th, 12th, and 18th postoperative month. Results: A total of 943 patients receiving microwave ablation or radiofrequency ablation in the years of 2018 and 2019 met our inclusion criteria. After 1:1 propensity score matching, 289 pairs of patients were matched. There was no significant difference between the two groups in operative duration, intraoperative blood loss, hospitalization time, overall cost, quality of life scores, complication rates or volume reduction rates. Conclusion: There was no significant difference between microwave and radiofrequency ablation in terms of safety and efficacy. Both of the two techniques` are ideal therapeutic methods in benign thyroid nodules treatment. Registration number: ChiCTR2000034764.

Factors predicting long-term outcomes of early-stage hepatocellular carcinoma after primary curative treatment: the role of surgical or nonsurgical methods.

BACKGROUND: We quantified the elusive effects of putative factors on the clinical course of early hepatocellular carcinoma (HCC) after primary surgical or nonsurgical curative treatment. METHODS: Patients with newly diagnosed early HCC who received surgical resection (SR) or percutaneous radiofrequency ablation (RFA) with or without transcatheter arterial chemoembolization (TACE) from January 2003 to December 2016 were enrolled. The cumulative overall survival (OS) and disease-free survival (DFS) rates were compared. A polytomous logistic regression was used to estimate factors for early and late recurrence. Independent predictors of OS were identified using Cox proportional hazard regression. RESULTS: One hundred twenty-five patients underwent SR, and 176 patients underwent RFA, of whom 72 were treated with TACE followed by RFA. Neither match analysis based on propensity score nor multiple adjustment regression yielded a significant difference in DFS and OS between the two groups. Multivariate analysis showed high AFP (> 20 ng/mL), and multinodularity significantly increased risk of early recurrence (< 1 year). In contrast, hepatitis B virus, hepatitis C virus and multinodularity were significantly associated with late recurrence (> 1 year). Multivariate Cox regression with recurrent events as time-varying covariates identified older age (HR = 1.55, 95% CI:1.01-2.36), clinically significant portal hypertension (CSPH) (HR = 1.97, 95% CI:1.26-3.08), early recurrence (HR = 6.62, 95% CI:3.79-11.6) and late recurrence (HR = 3.75, 95% CI:1.99-7.08) as independent risk factors of mortality. A simple risk score showed fair calibration and discrimination in early HCC patients after primary curative treatment. In the Barcelona Clinic Liver Cancer (BCLC) stage A subgroup, SR significantly improved DFS compared to RFA with or without TACE. CONCLUSION: Host and tumor factors rather than the initial treatment modalities determine the outcomes of early HCC after primary curative treatment. Statistical models based on recurrence types can predict early HCC prognosis but further external validation is necessary.

Imaging-guided radiofrequency ablation of osteoid osteoma in typical and atypical sites: Long term follow up.

PURPOSE: To assess efficacy and safety of imaging-guided radiofrequency ablation (RFA) of Osteoid Osteoma (OO) in both typical and atypical sites. METHODS AND MATERIALS: Between January 2014 and March 2019, 102 consecutive percutaneous RFA were performed and retrospectively reviewed. The procedures were performed using a RFA bipolar ablation system (Covidien, exposed tip of 0.7-1cm), under Computed Tomography (CT) guidance or using a navigation system (Masmec) under CT and Cone Beam CT (CBCT) guidance. Patients were followed up over 24 months. Clinical success and recurrences were considered on the base of established criteria. In patients with clinical failure and/or imaging evidence of relapse, retreatment was considered. RESULTS: Administered power per-procedure was ≤8 W (mean temperature, 90°C). The pre-procedure average value of visual analog scale (VAS) was 8.33+/-0.91. Primary and secondary success rate 96.08% (98/102) and100% (102/102), respectively. No major complication was described. Technical success was proved in every patient by CT scan acquisition after needle positioning. Relapse and tumour location were significantly correlated (p-value = 0.0165). The mean dose-length product was 751.55 mGycm2. Advanced bone healing was noted in 68 lesions after 1y-follow up and in 86 lesions after 2y-follow up. CONCLUSION: Imaging-guided percutaneous RFA is a highly effective technique for OO, both in typical and atypical sites. CT or CBCT guidance, navigation systems and operator experience grant the technical success, which is the most crucial parameter affecting outcome.

Utility of unilateral versus bilateral venous reflux studies for venous insufficiency.

OBJECTIVE: Duplex ultrasonography is the reference standard for diagnosing chronic venous insufficiency. Bilateral venous reflux ultrasound studies are among the most time-consuming and physically demanding tests for vascular ultrasound technologists to perform. Furthermore, if a venous procedure is required, many insurance policies require that a diagnostic venous ultrasound scan for reflux must be performed within 1 year of the procedure. If the intervention is scheduled for >1 year after the ultrasound scan, the insurance company might require a repeat venous ultrasound scan before granting insurance authorization. Hence, ordering bilateral venous duplex ultrasound scans to evaluate for reflux when an intervention might only be performed on one limb within the year could be a waste of time and resources. The aim of the present study was to determine the utility of ordering bilateral vs unilateral studies to evaluate for reflux in patients with suspected chronic venous insufficiency and to determine whether a resource-saving potential exists for vascular laboratories through optimization of the process of ordering venous duplex ultrasound studies. METHODS: A retrospective review of all patients who had undergone bilateral lower extremity ultrasound scanning to evaluate for reflux from January 1, 2016 to December 31, 2016 at the Massachusetts General Hospital vascular laboratory was performed. The demographics, indications for ultrasound scanning, comorbidities, time required to perform the ultrasound study, and interval to intervention were documented. The data were analyzed using SPSS statistical software (IBM Corp, Armonk, NY). RESULTS: During the study period, 13,854 ultrasound studies had been performed in our vascular laboratory, of which 606 (4.4%) had been bilateral ultrasound scans for venous insufficiency. The time allotted for a bilateral study was 2 hours. Of the 606 studies evaluated, 152 (25.1%) showed no evidence of reflux, 284 (46.9%) showed bilateral lower extremity reflux, and 170 (28.1%) showed only venous insufficiency in one leg. Venous ablation, phlebectomy, and/or sclerotherapy were performed for 28.7% of the patients. However only 6.2% of patients had undergone venous procedures on both legs within 1 year after the ultrasound studies. Ablation was the most common procedure performed (54.6%), followed by phlebectomy (27.%) and sclerotherapy (17.9%). Overall, 94.7% of patients had not undergone a venous procedure on both legs within 1 year after the ultrasound studies and, hence, would have required a repeat duplex ultrasound scan to ensure insurance coverage for future procedures. CONCLUSIONS: Most bilateral ultrasound scans for venous insufficiency will not result in an intervention. Thus, most patients (95%) could have undergone a unilateral scan before the initial intervention instead of bilateral duplex ultrasound scanning.

Influence of indications on perinatal outcomes after radio frequency ablation in complicated monochorionic pregnancies: a retrospective cohort study.

BACKGROUND: Radiofrequency ablation (RFA) is recommended to prevent potential neurological injury or intrauterine foetal death (IUFD) of the co-twin(s) in complicated monochorionic (MC) pregnancies. However, the impacts of various indications on the pregnancy outcome following RFA remain unclear. This study aimed to determine how the indications influence the perinatal outcomes in complicated MC pregnancies undergoing radiofrequency ablation. METHODS: This was a retrospective cohort study performed in a single centre. All consecutive MC pregnancies treated with RFA between July 2011 and July 2019 were included. The adverse perinatal outcomes and the survival rate were analysed based on various indications. The continuous variables with and without normal distribution were compared between the groups using Student's t-test and Mann-Whitney U test, respectively, and for categorical variables, Chi-square and Fisher's exact tests were used. P < 0.05 indicated a significant difference. RESULTS: We performed 272 RFA procedures in 268 complicated MC pregnancies, including 60 selective intrauterine growth restriction (sIUGR), 64 twin-twin transfusion syndrome (TTTS), 12 twin reversed arterial perfusion sequence (TRAPs), 66 foetal anomaly and 66 elective foetal reduction (EFR) cases. The overall survival rate of the co-twin was 201/272 (73.9%). The overall technical successful rate was determined at 201/263 (76.7%). The IUFD rate in the co-twin was 20/272 (7.4%). The TTTS group had recorded the lowest survival rate (37/64, 57. 8%), and the survival rate was significantly correlated with Quintero stages (P = 0.029). Moreover, the sIUGR III subgroup had a lower survival rate compared with sIUGR II (55.6%, versus 84.3%). The subgroup of foetal anomaly of gastroschisis or exomphalos had the highest IUFD rate (4/10, 40%), followed by sIUGR III (2/9, 22.2%) and dichorionic triamniotic (DCTA) subgroup (8/46, 17.9%). In EFR group, eight IUFD cases were all coming from the DCTA subgroup and received RFA before 17 weeks. CONCLUSIONS: The perinatal outcome of RFA was correlated with the indications, with the lowest survival rate in TTTS IV and the highest IUFD incidence in abdominal wall defect followed by sIUGR III. Elective RFA after 17 weeks may prevent IUFD in DCTA pregnancies.

Selective fetal reduction in complicated monochorionic twin pregnancies: A comparison of techniques.

OBJECTIVE: To compare perinatal outcomes associated with three methods of selective reduction in complicated monochorionic (MC) twin pregnancies: bipolar cord coagulation (BC), fetoscopic or ultrasound guided laser cord occlusion and radiofrequency ablation (RFA). METHODS: Retrospective cohort study of complicated MC twin pregnancies undergoing selective fetal reduction at a tertiary fetal center over a 20-year period. Obstetric and perinatal outcomes were compared. RESULTS: 105 procedures met inclusion criteria: 74 RFAs, 17 lasers and 14 BCs. Procedure duration was significantly shorter for RFA (27.4 ± 15.8 minutes) compared to BC (91.7 ± 38.7 minutes) and laser (83.4 ± 40.4 minutes), P < .0001). The incidence of preterm prelabor rupture of membranes (PPROM) and co-twin demise did not differ between groups, however preterm delivery <34 weeks occurred less frequently following RFA (29.7%), compared to laser (64.7%) or BC (42.9%) (P = .02); delivery <37 weeks was also less frequent following RFA (45.9%), compared to laser (76.5%) or BC (78.6%)(P = .01). The difference in preterm birth<34 weeks between RFA and laser was maintained after adjusting for cord occlusion indication and amnionicity (OR 3.96, 95% CI 1.27-12.31). CONCLUSIONS: In our experience, RFA procedures were simpler, faster and associated with a lower risk of preterm delivery <34 and <37 weeks, compared to laser or BC.

Feasibility and safety of surgical microwave ablation for hepatocellular carcinoma in elderly patients: a single center analysis in Japan.

The feasibility and safety of microwave ablation in elderly hepatocellular carcinoma (HCC) patients remains unknown. The aim of this study was to evaluate the feasibility and safety of surgical microwave ablation for HCC in patients older than 80 years of age. This retrospective study enrolled consecutive 114 patients older than 80 years of age who underwent surgical microwave ablation for HCC between July 1994 and December 2017. We analyzed perioperative outcomes and long-term outcomes to clarify the prognostic factors. The 1-, 3-, 5-year overall survival and recurrence-free survival rates were 97.3%, 76.0%, 49.2% and 84.2%, 44.7%, and 32.5%, respectively. The overall major morbidity rates (Clavien-Dindo grade IIIA or above) were 2.6%. There were no cases of mortality. Multivariate analysis showed that hepatitis C virus antibody (HCV-Ab) positivity and the presence of multiple tumors were independent prognostic factors for long-term outcomes. The overall survival rate of patients with HCV-Ab negative and single tumor was better than that of other patients (p = 0.026). Surgical microwave ablation was feasible and safe for elderly patients with HCC. Elderly patients with HCV-Ab negative and single tumor would be expected to have better long-term outcomes after surgical microwave ablation.

Repeat ablative therapy in hereditary or multifocal renal cancer: Functional and oncological outcomes.

OBJECTIVES: To report managing renal tumors in patients at greater risk of repeated interventions (genetic predisposition, multifocal tumors) with thermoablative treatments (AT). A known significant challenge in these patients is the balance between nephron preservation and oncologic outcome. MATERIAL AND METHODS: This retrospective, single-center study was based on data from patients treated with one or more AT for hereditary or multifocal renal tumors between 2007 and 2017. All medical records were systematically reviewed, and 10 patients meeting inclusion criteria were selected. Six patients had confirmed von Hippel-Lindau disease, 1 Bird-Hogg-Dubé syndrome, 1 chromosome 3 translocation, and 2 had a presumed genetic predisposition. RESULTS: Median age at cancer diagnosis was 39.5 years (±8.9). Fifty-seven tumors, including 41 de novo tumors that appeared during follow-up, were treated with 32 AT sessions (cryotherapy or radiofrequency) with an average tumor size of 13.5 mm (±9) and a median RENAL score of 6 [5; 7]. One patient underwent concomitant partial nephrectomy for a 55 mm lesion which was close to the bowel. Treatment was unsuccessful in 2 cases, subsequently managed successfully by retreatment with AT. Median delay of appearance of de novo tumor after the first AT was 18 months [6 ; 24]. One patient had metastatic progression. Overall and cancer specific survival was 90% and 100%, respectively, with a mean follow-up of 7.5 years (±4.9). The mean decrease in Chronic Kidney Disease - Epidemiological Collaboration equation-estimated glomerular filtration rate at the end of follow-up was 5.5 ml/min/1.73 m2 (±24). CONCLUSION: This study suggests that AT allows to meet the oncological objectives whilst preserving renal function in patients with renal cancer at greater risk of repeated treatments.

Liver Metastases-directed Therapy in the Management of Oligometastatic Breast Cancer.

INTRODUCTION: In the context of metastatic breast cancer, dissemination to the liver is a frequent occurrence. We aimed to evaluate the outcome and toxicity of metastatic breast cancer with liver oligometastases treated with metastases-directed therapies (MDTs), including surgery, stereotactic body radiation therapy, or thermal ablation (radiofrequency or microwaves). PATIENTS AND METHODS: We included patients with diagnosis of 1 to 5 liver metastases. Selection criteria included also age > 18 years; Eastern Cooperative Oncology Group performance status 0 to 2; absence of extra-hepatic disease or other controlled metastatic sites. Endpoints were liver progression-free survival (LPFS), progression-free survival (PFS), and overall survival. RESULTS: A total of 72 patients were included. Previous local treatments were performed in 13 (18.1%) patients, whereas systemic therapy was used in 81.9% of cases. Treatment of choice was stereotactic body radiation therapy in 54 (75%) patients followed by surgery (13 patients; 18%) and thermal ablation (5 patients; 7%). With a median follow-up of 26.2 months, LPFS at 1 and 2 years was 52.4% and 38.8%, respectively. The number of metastases predicted LPFS (hazard ratio [HR], 1.70; P = .004). Rates of PFS were 38.7% and 22% at 1 and 2 years, respectively. Systemic therapy before MDT (HR, 2.89; P = .016) was correlated with PFS. Overall survival at 1 and 2 years was 95.5% and 76.9%, respectively. Human epidermal growth factor receptor 2 status correlated with survival (HR, 1.82; P = .010). CONCLUSION: Combination of systemic therapy with liver MDT in oligometastatic breast cancer results in durable disease control in a significant proportion of patients. Tumor biology, prior treatment, and extent of disease may be useful to guide the decision to add MDT to standard therapy.

Management of benign prostatic hyperplasia in the 21st century: temporal trends in Australian population-based data.

OBJECTIVE: To examine national trends in the medical and surgical treatment of benign prostatic hyperplasia (BPH) using Australian Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) population data from 2000 to 2018. PATIENTS AND METHODS: Annual data was extracted from the MBS, PBS and Australian Institute of Health and Welfare databases for the years 2000-2018. Population-adjusted rates of BPH procedures and medical therapies were calculated and compared in relation to age. Cost analysis was performed to estimate financial burden due to BPH. RESULTS: Overall national hospital admissions due to BPH declined between 2000 and 2018, despite an increased proportion of admissions due to private procedures (42% vs 77%). Longitudinal trends in the medical management of BPH showed an increased prescription rate of dutasteride/tamsulosin combined therapy (111 vs 7649 per 100 000 men) and dutasteride monotherapy (149 vs 336 per 100 000 men) since their introduction to the PBS in 2011. Trends in BPH surgery showed an overall progressive increase in rate of total procedures between 2000 and 2018 (92 vs 133 per 100 000 men). Transurethral resection of the prostate (TURP) remained the most commonly performed surgical procedure, despite reduced utilisation since 2009 (118 vs 89 per 100 000 men), offset by a higher uptake of photoselective vaporisation of prostate, holmium:YAG laser enucleation of prostate, and later likely due to minimally invasive surgical therapies including prostatic urethral lift and ablative technologies (including Rezum™). Financial burden due to BPH surgery has remained steady since 2009, whilst the burden due to medical therapy has risen sharply. CONCLUSION: Despite reduced national BPH-related hospitalisations, overall treatment for BPH has increased due to medical therapy and surgical alternatives to TURP. Further exploration into motivators for particular therapies and effect of medical therapy on BPH progression in clinical practice outside of clinical trials is warranted.

Pre-sarcopenia is the prognostic factor of overall survival in early-stage hepatoma patients undergoing radiofrequency ablation.

Sarcopenia might have impact on the outcome of patients with hepatoma carcinoma (HCC). This study was to determine whether pre-sarcopenia is associated with the outcome of HCC patients undergoing radiofrequency ablation (RFA).Patients with newly diagnosed HCC undergoing RFA were enrolled. We excluded patients without pre-RFA abdominal computed tomography or with incomplete ablation. Psoas muscle area index was calculated at the mid-lumbar 3 level of computed tomography images with the manual trace method. Pre-sarcopenia was defined as psoas muscle area index less than 4.24 and 2.50 cm/m for males and females respectively. The demographics and clinical characteristics were recorded before RFA.All patients were followed regularly until death or end of 2018. A total of 136 patients, including - BCLC stage 0 (n = 44, 32.4%) and - stage A (n = 92, 67.6%), were enrolled (males/females: 78/58, age: 65.4 years) with a mean follow-up period of 3.84 years. There were 75 patients (55.1%) with HCC recurrence and 47 patients (34.6%) with mortality during follow-up. Twenty-two (16.2%) patients were diagnosed with pre-sarcopenia. Multivariate analysis showed pre-sarcopenia (HR: 2.110 (1.092-4.078); P = .026) was the only factor significantly associated with overall survival (OS); however, there were no factors associated with HCC recurrence.For patients without and with pre-sarcopenia, the 1-, 3-, and 5-year OS rates were 92.0%, 77.6%, 68.9%, and 81.8%, 54.5%, 44.1% respectively (P = .007). For early-stage HCC patients undergoing RFA, pre-sarcopenia is the prognostic factor of OS, but not of recurrence, with a worse 5-year OS rate of 44.1%.

A Prospective Intervention Trial on Tailored Radiofrequency Ablation of Uterine Myomas.

Background and Objective: Investigating the use of radiofrequency myolysis (RFM) for the treatment of fibroids through less invasive access by combining transvaginal ultrasound, hysteroscopy and laparoscopy. Materials and Methods: Fifty-four premenopausal women with 106 symptomatic uterine myomas. Patients underwent RFM in three ways: Vaginal Ultrasound-guided RFM (VU-RFM), Laparoscopic RFM (L-RFM) and Hysteroscopic-RFM (H-RFM). The mean patient age was 43 years; 52 symptomatic uterine myomas were subserosal, 44 intramural and 10 submucosal. The outcomes evaluated at 1 and 12 months after RFM were myoma size (volume-diameter), "Uterine Fibroid Symptom and Quality of Life (UFS-QOL)" questionnaire and a 10-point Visual Analogue Scale (VAS). The therapy was completed with a single ablation in all patients, no complication was registered. The average number of fibroids treated per intervention was two with the use of different accesses: 64/106 VU-RFMs (60.4%), 32/106 L-RFMs (30.2%) and 10/106 H-RFMs (9.4%). Results: Volume and diameter of fibroids were significantly reduced by, respectively, 51.3% and 20.1% in the first 30 days post-intervention (p < 0.001) up to a maximum of 73.5% and 37.1% after the second follow-up visit at 12 months (p < 0.001). A similar trend was shown in terms of disability with a progressive and significant reduction of symptoms (menorrhagia, dysmenorrhea, dyspareunia and pollakiuria) demonstrated by percentage variation of UFS-QOL Symptom Severity and VAS scores to -74.3% and -45.3% as well as -84.9% and -74.3%, respectively, at 1 and 12 months after RFM (p < 0.001). An overall improvement in the quality of life was also demonstrated by a significant increase in the UFS-QOL total score of +38.2% in the first 30 days post-intervention up to +44.9% after the second follow-up visit at 12 months (p < 0.001). The overall average surgery time of the RFM for each patient was 48 minutes, and the time to treat each fibroid by Vaginal Ultrasound-guided RFM (23 min) was found to be significantly less than those of laparoscopy or hysteroscopy (respectively 35 and 34 min) (p < 0.05). An electromagnetic virtual needle tracking system (VNTS) was successfully tested during the RFM procedures, and real-time contrast-enhanced ultrasound (CEUS) has proven to be effective in determining the duration of myolysis through the identification of eventual residual areas of enhancement within the fibroids. Conclusion: Radiofrequency can be considered a minimally invasive and safe procedure for the treatment of uterine myomas through the customization and possible combination of transvaginal, laparoscopic or hysteroscopic accesses. The standardization of the ablation technique with pre-intervention biopsy and new technologies such as VNTS and CEUS spares healthy uterine tissue and may change the future management of symptomatic uterine fibroids.

Stereotactic body radiation therapy vs. radiofrequency ablation in Asian patients with hepatocellular carcinoma.

BACKGROUND & AIMS: Few studies have been conducted to compare the efficacies of stereotactic body radiation therapy (SBRT) and radiofrequency ablation (RFA). Thus, in this multinational study, we compared the effectiveness of SBRT and RFA in patients with unresectable HCC. METHODS: The retrospective study cohort included 2,064 patients treated in 7 hospitals: 1,568 and 496 in the RFA and SBRT groups, respectively. More than half of the patients (56.5%) developed recurrent tumors, mainly after transarterial chemoembolization (44.8%). Propensity score matching was performed to adjust for clinical factors (n = 313 in each group). RESULTS: At baseline, the SBRT group had unfavorable clinical features compared to the RFA group, including BCLC stage (B-C 65% vs. 16%), tumor size (median 3.0 cm vs. 1.9 cm), and frequent history of liver-directed treatment (81% vs. 49%, all p <0.001). With a median follow-up of 27.7 months, the 3-year cumulative local recurrence rates in the SBRT and RFA groups were 21.2% and 27.9%, respectively (p <0.001). After adjusting for clinical factors, SBRT was related to a significantly lower risk of local recurrence than RFA in both the entire (hazard ratio [HR] 0.45, p <0.001) and matched (HR 0.36, p <0.001) cohorts. In subgroup analysis, SBRT was associated with superior local control in small tumors (≤3 cm) irrespective of location, large tumors located in the subphrenic region, and those that progressed after transarterial chemoembolization. Acute grade ≥3 toxicities occurred in 1.6% and 2.6% of the SBRT and RFA patients, respectively (p = 0.268). CONCLUSIONS: SBRT could be an effective alternative to RFA for unresectable HCC, particularly for larger tumors (>3 cm) in a subphrenic location and tumors that have progressed after transarterial chemoembolization. LAY SUMMARY: It is currently not known what the best treatment option is for patients with unresectable hepatocellular carcinoma. Here, we show that stereotactic body radiation therapy provides better local control than radiofrequency ablation, with comparable toxicities. Stereotactic body radiation therapy appears to be an effective alternative to radiofrequency ablation that should be considered when there is a higher risk of local recurrence or toxicity after radiofrequency ablation.