Exploring the Evolving Landscape of Stereotactic Body Radiation Therapy in Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) carries significant morbidity and mortality. Management of the HCC requires a multidisciplinary approach. Surgical resection and liver transplantation are the gold standard options for the appropriate settings. Stereotactic body radiation therapy (SBRT) has emerged as a promising treatment modality in managing HCC; its use is more studied and well-established in advanced HCC (aHCC). Current clinical guidelines universally endorse SBRT as a viable alternative to radiofrequency ablation (RFA), transarterial chemoembolisation (TACE), and transarterial radioembolisation (TARE), a recommendation substantiated by literature demonstrating comparable efficacy among these modalities. In early-stage HCC, SBRT primarily manages unresectable tumours unsuitable for ablative procedures such as microwave ablation and RFA. SBRT has been incorporated as a modality to downstage tumours or as a bridge to transplant. In the case of intermediate or advanced HCC, SBRT offers excellent results either as a single modality or adjunct to other locoregional modalities such as TACE/TARE. Recent data from late-stage HCC patients illustrate the effectiveness of SBRT in achieving local tumour control while minimising damage to surrounding healthy liver tissue. It has promising local control of approximately 80-90% in managing HCC. Additional prospective data comparing the efficacy of SBRT with the first-line recommended therapies such as RFA, TACE, and surgery are essential. The standard of care for patients with advanced/metastatic disease is systemic therapy (immunotherapy/tyrosine kinase inhibitors). SBRT, in combination with immune-checkpoint inhibitors, has an immune-modulatory effect that results in a synergistic effect. Recent findings indicate that the combination of immunotherapy and SBRT in HCC is well-tolerated and exhibits synergistic effects. Further exploration of diverse immunotherapy and radiotherapy strategies is essential to identify the appropriate time for combination treatments and to optimise dose and fraction regimens. Prospective, randomised studies are imperative to establish SBRT as the primary treatment for HCC.

Evaluating the Prognostic Significance of Cystatin C Level Variations Pre- and Post-Radiofrequency Catheter Ablation in the Recurrence of Persistent Atrial Fibrillation.

OBJECTIVE: To investigate the correlation between persistent atrial fibrillation (AF) recurrence and alterations in cystatin C levels pre- and post-radiofrequency catheter ablation (RFCA). METHODS: This study encompassed 114 patients diagnosed with persistent AF. Their serum cystatin C levels were assessed both prior to and 3 months after undergoing an RFCA procedure. The variance in cystatin C levels before and after RFCA is represented as ΔCystatin C. Subsequently, we compared these values between two groups: patients who did not experience a recurrence of AF (n = 79) and those who did experience a recurrence (n = 35). RESULTS: A significant reduction in cystatin C levels post-RFCA in both groups, with a more pronounced decrease observed in the non-recurrence group. Moreover, the recurrence group exhibited larger left atrial diameter and volume before RFCA compared to the non-recurrence group. Cox regression analysis indicated that smaller reductions in serum cystatin C levels and greater left atrial volumes before RFCA were associated with an increased risk of recurrence, after adjusting for covariates. The receiver operating characteristic curve indicated an elevated probability of clinical recurrence of AF post-RFCA in patients with a cystatin C decline < 0.08 mg/L (AUC 0.64). The Kaplan-Meier survival analysis revealed that patients with a cystatin C decline > 0.08 mg/L exhibited significantly higher rates of remaining free from recurrence following RFCA across a 24-month follow-up period (Log-rank test p = 0.003). CONCLUSIONS: Alterations in ΔCystatin C levels pre and post-RFCA in the initial phase could independently predict the recurrence of AF.

Intravenous thrombolysis following dabigatran reversal in a patient with acute embolic stroke after atrial fibrillation ablation.

This case demonstrated the feasibility of administering emergent intravenous thrombolysis followed by Dabigatran reversal with idarucizumab in a patient who underwent atrial fibrillation ablation. The consideration of transitioning anticoagulant therapy to dabigatran for scheduled AF ablation in patients at high risk of stroke should be carefully evaluated.

Using point-of-care ultrasound to determine incidence of deep vein thrombosis after right-sided radiofrequency catheter ablation.

Introduction: Femoral venous access is routinely used for radiofrequency catheter ablation (RFA) procedures. Deep vein thrombosis (DVT), which is often sub-clinical, is uncommon following RFCA. Point-of-care ultrasound (POCUS) is a cost-effective way to diagnose DVT. Identification of DVT incidence, especially if sub-clinical, can direct change in practice to reduce DVT and lay ground for cost-effective screening strategies postprocedures. The aim of our study is to determine the incidence of DVT after right-sided radiofrequency cardiac catheter ablation using POCUS. Methods: We conducted a single-center prospective cross-sectional study in patients undergoing right-sided RFCA. Within 24 h postprocedure, the participants underwent compression venous duplex ultrasonography using POCUS to look for evidence of DVT in cannulated limb. The contralateral limb that was not cannulated was scanned as a control. Results: A total of 194 patients were scanned post-right-sided RFCA procedures. Average age was 43.5 ± 13.2 years and 131 (67.5%) were women. A total of 148 (76.3%) patients underwent AVNRT ablation. Ten (5.2%) patients developed DVT, of which nine had sub-clinical DVT. Age (>53 years), greater sum of sheaths used (>3) and longer duration of bed rest maintained (up to 4.0 h vs. >4.0 h, p = 0.006) were identified as risk factors. Conclusion: Most of the DVTs after right-sided catheter ablation are sub-clinical. Routine scanning for DVT after right-sided catheter ablation as well as reducing number of sheaths and bed rest should be considered.

Advanced 3D Anatomical Mapping of Saphenous and Inferior Medial Genicular Nerve Branching: Enhancing Precision in Knee Joint Denervation.

BACKGROUND: Radiofrequency ablation is a common non-opioid treatment to manage chronic knee pain. The inferior medial genicular nerve is conventionally targeted. It has been suggested that the infrapatellar branch(saphenous nerve) should also be targeted. There is controversy regarding the contribution of the infrapatellar branch to the innervation of the knee joint capsule. OBJECTIVE: 1) Identify the frequency of the branching pattern(s) of the infrapatellar branch in 3D; 2) Assess spatial relationships of branches of infrapatellar branch to the inferior medial genicular nerve; 3) Determine if capturing infrapatellar branch could result in additional benefit to the existing protocol. DESIGN: Anatomical Study. METHODS: The infrapatellar branch and inferior medial genicular nerve were serially dissected, digitized, and modelled in 3D in 7 specimens(mean age 57.8 ± 2.0; 2F/5M) and their relationship documented. The spatial relationship of the nerves was used to assess the anatomical efficacy of including the infrapatellar branch in the protocol. RESULTS: The infrapatellar branch is most frequently a cutaneous nerve. This nerve was variable and found to be unbranched or have 2-3 branches and in all specimens was located superficial to the branches of inferior medial genicular nerve. When the infrapatellar branch (1) coursed more distally, the strip lesion would not capture the infrapatellar branch but would capture inferior medial genicular nerve consistently;(2) overlapped with the inferior medial genicular nerve, the strip lesion would capture both nerves. CONCLUSIONS: Proposed protocol targeting the infrapatellar branch is likely to capture the inferior medial genicular consistently regardless of the anatomical variation of the infrapatellar branch.

A New Approach with Combined Microneedle and Sublative Fractional Radiofrequency for Photoaging Management: A Clinical, Histometric, and Immunohistochemical Study.

BACKGROUND: Fractional radiofrequency (FRF) has been reported to be effective in improving wrinkles. A combination of microneedle and sublative fractional radiofrequency (SFRF) may have the potential synergy to improve photoaged skin. OBJECTIVES: To evaluate the efficacy and safety of combined microneedle and SFRF in photoaging management. METHODS: This prospective study included 12 subjects with moderate photoaging (skin phototype III-IV). The subjects received three consecutive combined microneedle and sublative FRF at 1-month intervals. Punch biopsies were obtained before and after three months of treatment. Routine H&E, Masson-trichrome, Orcein staining, histometric measurements, as well as Collagen type I and Elastin immunohistochemical staining were performed. RESULTS: Significant improvement was noticed regarding skin tightening and texture (p < 0.05), rhytides, and volunteers' satisfaction (p < 0.001). Collagen fibers appeared better organized, with a significant increase in collagen type I (p = 0.001). Meanwhile, normal-appearing elastic fibers were restored, and a significant reduction in abnormal elastin was achieved (p = 0.0005). CONCLUSION: Combined microneedle and sublative FRF may provide a new therapeutic approach for photoaged skin. LEVEL OF EVIDENCE II: For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Prognostic Value of Burst Pacing Inducibility Post-Radiofrequency Versus Cryoablation for Paroxysmal Atrial Fibrillation.

BACKGROUND: Atrial fibrillation (AF) inducibility with burst pacing (BP) after radiofrequency ablation (RFA) has been reported to be associated with AF recurrence. In contrast, the relevance of inducibility and recurrence after cryoablation (CRA) is unclear. METHODS: We investigated 367 patients undergoing initial ablation for paroxysmal AF (RFA: 174, CRA: 193). Propensity score matching was conducted, retaining 134 patients in each group. Following pulmonary vein isolation (PVI), the inducibility by BP was tested. Inductions at 250 ppm were defined as low-frequency burst pacing (LFBP) positive, and those at 300 ppm were classified as medium-frequency burst pacing (MFBP) positive. They were followed for 600 days. RESULTS: Forty-eight patients (18%) had AF recurrence. There was no significant difference in the recurrence rate between RFA and CRA (17% vs. 19%, Log-rank p = 0.79). In RFA, significant differences were observed for both LFBP (Log-rank p < 0.001) and MFBP (Log-rank p < 0.001). In contrast, in CRA, there were no significant differences for either LFBP (Log-rank p = 0.39) or MFBP (Log-rank p = 0.19). Multivariable analysis revealed that LFBP-positive (hazards ratio [HR] = 5.75, 95% confidence interval [CI] 2.41-13.7, p < 0.001) was an independent predictor for recurrence with RFA. Acute reconnection (HR = 2.73, 95% CI 1.13-6.56, p = 0.025) was an independent predictor for recurrence with CRA. CONCLUSION: The inducibility by BP after RFA predicted recurrence at both low and medium frequencies. LFBP-positive was an independent predictor of recurrence in multivariable analysis. In contrast, the inducibility by BP after CRA was not a predictor of recurrence. TRAIL REGISTRATION: This study did not require clinical trial registration.

EUS-Guided Radiofrequency Ablation Therapy for Pancreatic Neoplasia.

Radiofrequency ablation (RFA) under endoscopic ultrasound (EUS) guidance has been developed and utilized over the last decade to provide the loco-regional treatment of solid and cystic pancreatic neoplastic lesions. The advantage of this approach relies on the close proximity of the EUS transducer to the target pancreatic lesion, which, coupled with the development of specifically designed RFA ablation devices, has made the procedure minimally invasive, with a clear reduction in adverse events as compared to the high morbidity of the surgical approach. EUS-RFA has been applied so far to pancreatic functional and non-functional neuroendocrine neoplasms, pancreatic ductal adenocarcinoma or metastases to the pancreas, and pancreatic neoplastic cysts. Excluding neuroendocrine tumors, for other indications, most of these procedures have been performed in patients who refused surgery or were at high surgical risk. More studies evaluating EUS-RFA in selected patients, not at surgical risk, are gradually becoming available and will pave the road to extend the indications for this therapeutic approach, also in association with other oncological therapies. The present manuscript will critically review the available evidence in the field of the EUS-guided RFA of solid and cystic pancreatic neoplasms.

3D ultrasound guidance for radiofrequency ablation in an anthropomorphic thyroid nodule phantom.

BACKGROUND: The use of two-dimensional (2D) ultrasound for guiding radiofrequency ablation (RFA) of benign thyroid nodules presents limitations, including the inability to monitor the entire treatment volume and operator dependency in electrode positioning. We compared three-dimensional (3D)-guided RFA using a matrix ultrasound transducer with conventional 2D-ultrasound guidance in an anthropomorphic thyroid nodule phantom incorporated additionally with temperature-sensitive albumin. METHODS: Twenty-four phantoms with 48 nodules were constructed and ablated by an experienced radiologist using either 2D- or 3D-ultrasound guidance. Postablation T2-weighted magnetic resonance imaging scans were acquired to determine the final ablation temperature distribution in the phantoms. These were used to analyze ablation parameters, such as the nodule ablation percentage. Further, additional procedure parameters, such as dominant/non-dominant hand use, were recorded. RESULTS: Nonsignificant trends towards lower ablated volumes for both within (74.4 ± 9.1% (median ± interquartile range) versus 78.8 ± 11.8%) and outside of the nodule (0.35 ± 0.18 mL versus 0.45 ± 0.46 mL), along with lower variances in performance, were noted for the 3D-guided ablation. For the total ablation percentage, 2D-guided dominant hand ablation performed better than 2D-guided non-dominant hand ablation (81.0% versus 73.2%, p = 0.045), while there was no significant effect in the hand comparison for 3D-guided ablation. CONCLUSION: 3D-ultrasound-guided RFA showed no significantly different results compared to 2D guidance, while 3D ultrasound showed a reduced variance in RFA. A significant reduction in operator-ablating hand dependence was observed when using 3D guidance. Further research into the use of 3D ultrasound for RFA is warranted. RELEVANCE STATEMENT: Using 3D ultrasound for thyroid nodule RFA could improve the clinical outcome. A platform that creates 3D data could be used for thyroid diagnosis, therapy planning, and navigational tools. KEY POINTS: Twenty-four in-house-developed thyroid nodule phantoms with 48 nodules were constructed. RFA was performed under 2D- or 3D-ultrasound guidance. 3D- and 2D ultrasound-guided RFAs showed comparable performance. Real-time dual-plane imaging may offer an improved overview of the ablation zone and aid electrode positioning. Dominant and non-dominant hand 3D-ultrasound-guided RFA outcomes were comparable.

Safety observation of antiarrhythmic drug use in a patient with sinus bradycardia following atrial fibrillation radiofrequency ablation combined with cardiac neural ablation: a case report.

This study assessed the safety of Antiarrhythmic Drug (AAD) administration in a patient experiencing sinus bradycardia following radiofrequency ablation for Atrial Fibrillation (AF), followed by cardiac ganglion ablation. Post-AF radiofrequency ablation, the employment of AADs is a prevalent clinical practice; however, these drugs may exacerbate bradycardia, leading to increased patient discomfort and treatment complexity. The decision to employ AADs in patients with sinus bradycardia post-AF ablation poses a significant clinical challenge. This investigation aimed to ascertain the safety of AADs in such patients. The study encompassed a single case, wherein a patient with pre- and post-procedure sinus bradycardia was treated with AADs following AF radiofrequency ablation and cardiac ganglion ablation, with a subsequent safety assessment. The findings indicate that AADs can be safely administered to patients with sinus bradycardia after these procedures, offering valuable insights for clinical decision-making. This case report underscores the intricacies of post-AF ablation management in patients with sinus bradycardia and advocates for personalized therapeutic strategies. The results enhance the clinical knowledge regarding the safety of AADs in this patient subset and may guide future treatment protocols. Nonetheless, the study's conclusions are drawn from a single case, and further research with larger cohorts is essential to substantiate these findings and elucidate the long-term safety and efficacy of this therapeutic approach.

Endoscopic Joint Capsule and Articular Process Excision for the Treatment of Lumbar Facet Joint Syndrome: A Retrospective Study.

Background: Dorsal ramus medial branch radiofrequency ablation is reported to be effective for refractory lumbar facet joint syndrome. However, as nerve fibers can regenerate, the therapeutic effect was reported to be short and last only 6 to 12 months. Previously, we reported a novel endoscopic joint capsule and articular process excision procedure. In that case, a satisfying effect was achieved by removing the culprit hyperplastic articular synovial entrapped in the joint space endoscopically. We presume this treatment is an etiologic treatment and can exert longer-term efficacy. Aim: This retrospective clinical trial aimed to elucidate the longer-term efficacy as well as the safety profile of the procedure. Methods: This was a retrospective descriptive study. The participants underwent endoscopic joint capsule and articular process excision procedures. The Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) before the operation, and at 3 months, 6 months, 1 year, and 2 years post-operation were recorded by reviewing medical charts and conducting telephone interviews. Results: A total of 234 participants were evaluated in the trial. After participant screening, 13 participants were included in the final analysis. The VAS score was reduced from (median (P25, P75)) 6 (4.5, 6) at pre-operation to 2 (0, 4) at 1-year post-operation and 0 (0, 1) at 2-year pre-operation. The ODI score was reduced from 37.78 (27.09, 59.95) at pre-operation to 8.89 (2.22, 24.34) at 1-year post-operation and 6 (0.02, 11.11) at 2-year post-operation. The difference was statistically significant. Further subgroup analysis demonstrated that a narrowed intervertebral space was a possible relevant factor for poor outcomes. No procedure-related complications were reported. Conclusion: Endoscopic joint capsule and articular process excision is an effective and safe procedure for refractory lumbar facet joint syndrome. The effectiveness duration can last up to 1 to 2 years.

Predictive Value of Current Perception Threshold for Prognosis of Pulsed Radiofrequency in Patients with Acute Herpetic Neuralgia.

Objective: This study aimed to evaluate the prognostic accuracy of the Current Perception Threshold (CPT) in Acute Herpetic Neuralgia (AHN) patients receiving Pulsed Radiofrequency (PRF) therapy and to develop a corresponding prognostic model. Methods: We retrospectively analyzed data from 106 AHN patients treated with PRF between January 2022 and May 2023. The occurrence of Postherpetic Neuralgia (PHN) after treatment categorized patients into non-PHN and PHN groups. The predictive role of CPT indices for PRF outcomes was assessed using the Receiver Operating Characteristic (ROC) curve and Area Under Curve (AUC). Then the dataset was split into a training set (n=74) and a validation set (n=32). Factors associated with PHN development were identified using univariate and multivariate logistic regression. A nomogram model was developed using significant predictors and internal validation was performed using valid set data. Results: Among the 106 patients, 45 had a poor prognosis. Significant differences in age, preoperative Numerical Rating Scale (NRS) score, and 5Hz CPT ratio were observed between the groups (p<0.05). Logistic regression identified these factors as independent predictors for PRF prognosis (p<0.05). The 5Hz CPT ratio demonstrated predictive value (AUC= 0.764, 95% CI: 0.674-0.855). The nomogram model, incorporating these predictors, showed high AUC in both the training (0.863, 95% CI: 0.776-0.950) and validation sets (0.859, 95% CI: 0.721-0.998). Calibration curves indicated good model fit, and the Hosmer-Lemeshow test confirmed this (p>0.05). Decision Curve Analysis (DCA) highlighted the model's predictive advantage. Conclusion: The 5Hz CPT ratio can predict the prognosis of PRF in AHN patients. The nomogram model has high precision and clinical utility. It can help identify AHN patients with a poor PRF prognosis at an early stage and assist in clinical decision-making.

Radiofrequency interference in magnetic resonance imaging: Identification and rectification.

Radiofrequency (RF) interference artifact is a common type of magnetic resonance imaging (MRI) artifacts caused by the presence of unwanted RF field inside the scanner room. The artifact has the appearance of parallel bright lines or bands that resemble zippers, which can mimic pathology, obstruct the viewing of underlining tissues, and lower image signal-to-noise ratio, affecting the diagnostic evaluation of the image and sometimes even rendering it non-diagnostic. Due to the presence of multiple possible sources of RF interference in MRI and potential nonrelated MRI artifacts that resemble RF interference artifact, it may be difficult to effectively and timely resolve the artifact problem. The objective of this paper is to provide a review of RF interference in MRI and to offer guidance in the prompt and correct identification of the associated image artifacts as well as efficient approaches to resolve and prevent RF interference problems. This article should serve as a useful educational reference to magnetic resonance (MR) technologists and radiologists in dealing with MR image artifacts that may be caused by RF interference.

Nano-Pulse Stimulation Therapy Initiates Regulated Cell Death in Skin, Unlike Bovie Radiofrequency Ablation and Cryoablation.

Background: This study describes a unique new bioelectric approach for clearing skin lesions and illustrates the clinical and histological differences between this new method and the standards of cryoablation and Bovie® radiofrequency ablation (RFA). Objectives: To determine the advantage of stimulating regulated cell death with nanosecond pulsed electric fields over the necrosis response elicited by thermal ablation modalities. Methods: Human abdominal skin was treated with cryoablation, Bovie® RFA, and nano-pulse stimulation (NPS) therapy four times before an abdominoplasty procedure was performed to collect skin for histology. The clinical appearance and corresponding histology of each treatment were documented over time and compared. Results: NPS therapy triggered regulated cell death as indicated by the appearance of activated Caspase-3 at 2 h post treatment and the absence of nuclear staining 1 day post treatment. Epidermal regeneration follows without impacting the noncellular dermis in contrast to cryoablation and Bovie® RFA which trigger necrosis and often cause scarring, inflammation, or permanent pigmentary changes. The main differences between NPS therapy and other ablation modalities are the level of fibrosis, amount of scarring, elastic fiber concentration, and inflammation. An analysis of the skin thickness 30 days after the treatment indicates that NPS-treated skin is the most similar to untreated skin but cryoablated and RF-ablated skin were 2- and 3.5-fold thicker, respectively, suggesting that they initiate necrosis rather than regulated cell death. Conclusions: We conclude that NPS therapy is a unique nonthermal modality that may be applied for clearing benign skin lesions by initiating the skin's own programmed cell death pathway instead of necrosis as used by cryoablation and Bovie® RFA.

Endoscopic Ultrasound-Guided Radiofrequency Ablation (EUS-RFA) for Pancreatic Adenocarcinoma: A Review.

Pancreatic ductal adenocarcinoma (PDAC) is still one of the deadliest neoplasms in the world. Although various advancements in the treatment and management of this disease have been made, no significant overall survival benefit has been achieved. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has been proposed as a treatment for patients who are unfit for surgery or with inoperable PDAC. We conducted a literature review of the PubMed and Embase databases to identify and analyze studies on the use of EUS-RFA in inoperable PDAC. Eleven studies with a total of 122 patients were analyzed to assess the population characteristics, feasibility and safety of the procedure, and overall survival of the population. Technical success was achieved in 95.1% of cases, and no intraoperative complications were reported. The most common early complication reported was abdominal pain (21 out of 122 patients) with a total early complication rate of 29.6%, and none of these complications affected hospital stays or post-procedure recovery. Late complications were reported in four patients (3.2%). Post-procedure cytoreduction was achieved in all patients, although disease progression was reported in 119 of 122 patients. The overall survival rate did not differ from that reported in the literature. We found that EUS-RFA could be a valid palliative option for inoperable patients, a bridge for surgery reducing the size of the tumor and its vascular relationship, or a first-line therapy in a subset of selected patients. Larger cohort and prospective studies should be conducted to establish guidelines for this procedure.

Topical Anesthesia Versus Submucosal Injection for Radiofrequency Turbinoplasty: Same Benefit but without Patient's Pain. A Comparative Study.

This study aimed at comparing the anesthetic efficacy of lidocaine injection versus pledgets soaked in lidocaine and epinephrine during radiosurgery of inferior turbinates. The study prospectively enrolled 120 outbound patients, who were randomly assigned to group 1 -anaesthesia with tampon soaked in lidocaine and adrenaline- or group 2 -anesthesia with tampon followed by lidocaine and adrenaline injection. The following parameters were evaluated by a visual analogue scale 1 h after surgery: pain, anxiety, chocking sensation and difficulty swallowing. Nasal obstruction, rhinorrhea, sneezing, headache and inferior turbinate size were evaluated preoperatively (T0), after 1 (T1), 2 (T2) and 3 months (T3) to surgery. The data collected were analyzed by statistic tests. Group 1 showed lesser pain than group 2 during the procedure (p < 0.01); no statistically significant differences were observed for anxiety, chocking sensation and difficulty swallowing. All patients, independently from the belonging group, significantly improved the nasal symptoms comparing T0 and T1 (p < 0.01), T2 (p < 0.01) and T3 (p < 0.01), without statistically significant differences among the groups. Radiofrequency turbinoplasty allowed to all patients to reduce the turbinates hypertrophy. Local anaesthesia with tampon allowed to obtain the same results the injective anaesthesia in term of surgical outcomes; the use of tampon allowed patients did not experience pain.