Innovative Fetal Therapy for a Giant Congenital Pulmonary Airway Malformation with Hydrops.

INTRODUCTION: Congenital pulmonary airway malformations (CPAMs) complicated by hydrops portend significant morbidity and mortality, with fetal survival estimates less than 10%. CASE PRESENTATION: We report successful use of ultrasound-guided radiofrequency ablation at 21-week gestation in a hydropic fetus with CPAM, with subsequent resolution of hydrops. Thirty-two-week MRI noted persistent mediastinal shift, and US at 36 weeks and 5 days noted polyhydramnios. Maternal gestational hypertension prompted delivery at 37 weeks, with a cesarean section performed after a failed trial of labor. The infant required CPAP at 100% and weaned to 21%. Tachypnea persisted, and chest CT on day of life 2 demonstrated multiple large cysts in the right lower lobe with anterior pneumothorax. On day of life 3, she successfully underwent a thoracoscopic right lower lobectomy. Adhesions to the chest wall and rib abnormalities were noted. She was extubated to CPAP at the conclusion of the procedure. She was able to wean to 21% on POD2 and transitioned to oral feeds. Her chest tube was removed with resultant ex vacuo pneumothorax noted. She remained asymptomatic and was discharged home on room air POD11. Pathology confirmed a type 1 CPAM. CONCLUSION: In utero radiofrequency ablation may be an adjunct to the management of large CPAM.

Preservation of Renal Function after Major Bleeding Events due to Ultrasound-Guided Parenchymal Renal Biopsy.

The clinical outcomes of major bleeding events following ultrasound-guided native and allograft parenchymal renal biopsy were evaluated. Forty-eight bleeding complications after biopsy (Society of Interventional Radiology adverse event grade ≥ 2) from 2002 to 2018 were identified. The primary outcome assessed was renal function. The clinical outcomes and interventions performed, including blood transfusion, angiography with or without embolization, nephrostomy tube placement, surgery, nephrectomy, hospitalization, intensive care unit admission, dialysis, and survival, were noted. Renal function may be moderately diminished in the short-term periprocedural setting. None of the patients studied died or required nephrectomy or the initiation of dialysis as a result of a major bleeding complication after the renal biopsy.

Percutaneous Image-Guided Thermal Ablation of Adrenal Metastasis from Melanoma: A Single-Institution Experience.

The outcomes of technically successful image-guided percutaneous thermal ablation of melanoma adrenal metastases involving 11 tumors in 9 consecutive patients over 12 years (2009-2020) were evaluated. All patients had multiple treated metastatic sites, and 44.4% (4/9) had greater than 5 metastatic sites. The mean maximal tumor diameter was 3.6 ± 1.6 cm. The local recurrence-free survival at 1 year was 85.7%. With a median survival of 19.4 months, 66.6% (6/9) of patients died from tumor progression. The 1- and 3-year overall survival rate was 60.0% and 30.0%, respectively. All patients were pretreated with alpha-adrenergic blockade, and 36% (4/11) developed a hypertensive crisis. The median hospital length of stay was 1 day (range, 1-2 days), without any major complications. Thermal ablation of adrenal metastasis from a melanoma provides acceptable local control and a good safety profile.

Percutaneous Image-Guided Core Needle Biopsy of Neuroendocrine Tumors: How Common Is Intraprocedural Carcinoid Crisis?

PURPOSE: To retrospectively evaluate the incidence of carcinoid crisis, other complications, and physiologic disturbances during percutaneous image-guided core needle biopsy of neuroendocrine tumors (NETs) in the lung and the liver. MATERIALS AND METHODS: Between January 2010 and January 2020, 106 computed tomography (CT) or ultrasound (US)-guided core needle biopsies of lung and liver NETs were performed in 95 consecutive adult patients. The mean age was 64 ± 13 years, and 48% were female. The small bowel was the most common primary site (33%, 31/95), and 32 (34%) patients had pre-existing symptoms of carcinoid syndrome. The mean tumor size was 3.2 ± 2.6 cm, and mean number of passes was 3.4 ± 1.6. A 17/18-gauge needle was used in 91% (96/106) of the biopsies. Thirteen (12%) patients received either outpatient or prophylactic octreotide. RESULTS: No patients experienced carcinoid crisis or needed octreotide, inotropes, vasopressors, or resuscitation. A single biopsy procedure (0.9%, 1/106) was complicated by bleeding that required angiographic hepatic artery embolization. Changes in pre-biopsy- versus post-biopsy systolic blood pressure and heart rate were -1.6 mm Hg (P = .390) and 0.6 beat/min (P = .431), respectively. Tumor functional status, overall tumor burden, and the elevation of neuroendocrine markers were not associated with intraprocedural physiologic disturbances. There were 4 minor complications (0.4%, 4/106) associated with the biopsy procedure that were not attributed to hormone excretion from tumor manipulation. CONCLUSIONS: Percutaneous image-guided core biopsy of NETs is safe, with low complication rate and no definite carcinoid crisis in the current cohort.

A Single-Institution Experience in Percutaneous Image-Guided Cryoablation of Lymph Node Metastases.

OBJECTIVE. The purpose of this study was to assess the feasibility, safety, and efficacy of percutaneous cryoablation for the treatment of lymph node metastases. MATERIALS AND METHODS. In this single-institution retrospective study 55 patients were identified who underwent CT-guided cryoablation of metastatic lymph nodes between November 2006 and September 2019. Patient demographics, disease characteristics, and procedural details were recorded. The primary endpoints were technical success and major complications. The secondary endpoints were time to local and time to distant progression. Complications were graded according to the Society of Interventional Radiology consensus guidelines. RESULTS. The study sample comprised 55 patients (42 men, 13 women; mean age 64 ± 12 years) who underwent 61 cryoablation procedures to treat 65 lymph node metastases. Targeted nodes measured 1.7 ± 1.2 cm in mean short-axis diameter. Technical success was achieved in 60 of 61 cryoablation procedures (98%). Adjunctive maneuvers performed to protect adjacent structures included hydrodissection (n = 40), ureteral stenting (n = 3), and neural monitoring (n = 3). There were two Society of Interventional Radiology major complications (3%): pneumothorax (n = 1) and bleeding (n = 1). Local tumor control was achieved in treatment of 53 of 65 (82%) nodal metastases within a median of 25 months (range, 1-121 months) of follow-up. Local progression occurred in 12 of 65 cases (18%); the median time to recurrence was 11 months. CONCLUSION. Percutaneous cryoablation of nodal metastases is feasible and safe. Further investigation is warranted to assess the long-term efficacy of this technique and to define its role in oncologic care.

Safety and Efficacy of Retrograde Pyeloperfusion for Ureteral Protection during Renal Tumor Cryoablation.

PURPOSE: To determine safety and efficacy of retrograde pyeloperfusion for ureteral protection during cryoablation of adjacent renal tumors. MATERIALS AND METHODS: Retrospective review of 155 patients treated with renal cryoablation, including adjunctive retrograde pyeloperfusion, from 2005 to 2019 was performed. Ice contacted the ureter in 67 of the 155 patients who represented the study cohort. Median patient age was 68 years old (interquartile range [61, 74]), 52 patients (78%) were male, and 37 tumors (55%) were clear cell histology. Mean tumor size was 3.4 ± 1.3 cm, and 42 tumors (63%) were located at the lower pole. Treatment-related complication and oncologic outcomes were recorded based on a review of post-procedural images and chart review. RESULTS: Technical success of cryoablation was attained in 67 cases (100%), and technical success of pyeloperfusion was attained in 66 cases (99%). A total of 13 patients (19.4%) experienced SIR major C or D complications related to the procedure, including hemorrhage (n = 4), urine leak (n = 3), transient urinary obstruction (n = 2), pulmonary embolism (n = 1), hypertensive urgency (n = 1), acute respiratory failure (n = 1), and ureteropelvic junction (UPJ) stricture (n = 1). No complications were attributable to pyeloperfusion. Three of 45 patients with biopsy-proven renal cell carcinoma experienced local recurrence resulting in local recurrence-free survival of 92% (95% confidence interval, 81.5%-100%) 3 years after ablation. CONCLUSIONS: Retrograde pyeloperfusion of the renal collecting system is a relatively safe and efficacious option for ureteral protection during renal tumor cryoablation. This adjunctive procedure should be considered for patients in whom cryoablation of a renal mass could potentially involve the ureter.

Effectiveness and Safety of Percutaneous CT-Guided Rib Biopsy.

PURPOSE: To retrospectively evaluate effectiveness and safety of percutaneous CT-guided rib biopsy. MATERIALS AND METHODS: CT-guided core rib biopsies were performed in 249 consecutive patients between January 2002 and June 2016. Mean patient age was 64.8 years ± 13.8. Additional patient demographics, rib lesion characteristics, and procedural techniques were reviewed. Diagnostic yield was assessed, and complications were classified using SIR criteria. RESULTS: Mean maximal diameter of 249 rib lesions was 2.7 cm ± 1.8, and 107 (43%) rib lesions had an associated extraosseous soft tissue component. Of rib lesions, 172 (69%) were lytic, 75 (30%) were sclerotic, and 2 (1%) were identifiable only with positron emission tomography/CT correlation. Specimens from 241 (96.8%) biopsies were adequate for pathologic diagnosis, whereas 8 (3.2%) were nondiagnostic. Of diagnostic biopsies, 168 (69.7%) were positive for malignancy; 73 (30.3%) revealed benign etiologies. There was a significant difference in diagnostic biopsy rate depending on size of the rib lesion (mean 2.8 cm ± 1.8 for diagnostic biopsies vs mean 1.3 cm ± 0.5 for nondiagnostic biopsies; P = .007). Of rib lesions, 170 (99%) lytic lesions and 69 (92%) sclerotic lesions yielded diagnostic biopsies; diagnostic biopsy rate was significantly higher for lytic lesions than sclerotic lesions (P = .01). There were 14 (5.6%) minor complications and no major complications. CONCLUSIONS: Percutaneous CT-guided core rib biopsy resulted in high diagnostic yield and low complications. Diagnostic biopsy rates were higher with larger lesion size and lytic rib lesions.

Periprocedural Major Bleeding Risk of Image-Guided Percutaneous Chest Tube Placement in Patients with an Elevated International Normalized Ratio.

PURPOSE: To evaluate the incidence of major hemorrhage after image-guided percutaneous chest tube placement in patients with an abnormal international normalized ratio (INR) measured before the procedure. MATERIALS AND METHODS: Between January 2013 and September 2017, 49 image-guided percutaneous chest tubes were placed in 45 adult patients who had an elevated INR of greater than 1.6. Data collected included routine serum pre-procedure coagulation studies, indication for chest tube placement, insertion technique, size of chest tube, and presence of complications after drain placement. Major bleeding complications were defined using the Society of Interventional Radiology classification system. RESULTS: Mean patient age was 62 years (range, 22-94 years), with median American Society of Anesthesiologists score of 4. Mean INR was 2.1 (range, 1.7-3), with 21 (43%) procedures with an INR between 1.7 and 1.9, 20 (41%) procedures with an INR between 2.0 and 2.4, and 8 (16%) procedures with an INR between 2.5 and 3.0. Computed tomography guidance was used for 27 (55%) procedures; ultrasound guidance was used for 22 (45%) procedures. Median size of chest tube was 10 Fr (range, 8-14 Fr) used in 27 (55%) procedures. No major bleeding complications were observed. There was a small, significant decrease in mean hemoglobin after the procedure (mean = 0.9g/dL; P < .0001), which correlated to increasing chest tube size (P = .0269). CONCLUSIONS: No major bleeding complications were observed after image-guided percutaneous chest tube placement in patients with an elevated INR. Major bleeding complications in these patients may be safer than initially considered, and this study encourages the conduct of larger trials for further evaluation.

Procedure-Related Pain During Image-Guided Percutaneous Biopsies: A Retrospective Study of Prevalence and Predictive Factors.

OBJECTIVE. The purpose of this study was to evaluate the prevalence and severity of pain reported during image-guided percutaneous biopsies and to identify factors associated with increased reported pain. MATERIALS AND METHODS. In this retrospective study, a database of adult patients who underwent CT- or ultrasound-guided percutaneous core needle biopsy between July 22, 2013, and February 1, 2018, was reviewed. Data collected included patient age and sex, biopsy site, biopsy type (lesion or parenchymal), needle gauge, number of passes, use of sedation, and whether it was the patient's first recorded biopsy. The maximum procedure-related pain reported on a 0-10 numeric rating scale was recorded. Multivariable logistic regression with generalized estimating equations was used to assess the association between covariates and patient-reported pain. RESULTS. A total of 13,344 biopsy procedures were performed in 10,474 patients. Patients reported no pain (0 of 10 scale) during 9765 (73.2%) procedures. Female sex, younger age at biopsy, undergoing IV sedation, and larger needle diameter were all associated with increases in patient-reported pain. Biopsies of renal allografts were the least likely to be painful, followed by hepatic allografts. CONCLUSION. Patients typically report mild or no pain from image-guided biopsy performed by radiologists. Younger patients and women report greater pain. This information can assist preprocedural counseling and reassurance of patients and may help them predict procedure-related patient needs.

Frequency of Bleeding Complications After Percutaneous Core Needle Biopsy and the Association With Aspirin Usage and Length of Aspirin Discontinuation.

OBJECTIVE. The purpose of this study is to report the frequency of major bleeding after percutaneous image-guided core biopsy and its association with aspirin usage and duration of prebiopsy aspirin abstinence. MATERIALS AND METHODS. A retrospective review of percutaneous image-guided core biopsies performed at our institution between September 1, 2005, and September 1, 2016, was performed (n = 30,966). Patients were excluded if aspirin usage data were missing (n = 633). Bleeding complications were defined using the Common Terminology Criteria for Adverse Events and were considered significant if they were grade 3 or higher. Multivariate models were adjusted for age, sex, platelet count, international normalized ratio, and biopsy target. Three categorizations of aspirin use were examined: any use within 10 days before biopsy, duration of abstinence (> 10 days or no aspirin, 8-10 days, 4-7 days, and 0-3 days before biopsy), and use on the day of biopsy. Associations with bleeding complications were modeled using logistic regression models. A p < 0.05 was considered significant. RESULTS. The study included 30,333 biopsies in 21,938 subjects (57% male; median age, 60 years; interquartile range, 49-70 years). Of the biopsies, 7921 (26.1%) were performed in patients who received aspirin within 10 days of biopsy, and 3761 (47.5%) of those biopsies were performed in patients who took aspirin within 3 days. Ninety-eight (0.32%) significant bleeding complications occurred overall, including 34 (0.43%) in patients who used aspirin within 10 days before biopsy (odds ratio, 1.5; 95% CI, 0.96-2.3; p = 0.08). Duration of abstinence was associated with a significantly increased bleeding risk only between 0-3 days versus more than 10 days or no aspirin (odds ratio, 2.1; 95% CI, 1.3-3.6; p = 0.004). Aspirin use on the day of biopsy showed the greatest increase in risk (1.9%; odds ratio, 6.6; 95% CI, 3.8-11.5; p < 0.001). CONCLUSION. Significant bleeding complications after biopsy remain rare even among patients with recent aspirin usage, although shorter duration of prebiopsy abstinence increases bleeding risk, most significantly if aspirin is taken the day of biopsy.

Patient-Reported Outcomes After Percutaneous Renal Ablation: Initial Experience.

OBJECTIVE: The purpose of this study is to assess patient-reported outcomes after renal tumor ablation. MATERIALS AND METHODS: A retrospective review of a pilot quality initiative from February 2016 to April 2016 in our renal ablation practice was performed to assess outcomes after treatment. This included a total of 38 patients (mean age, 63 years; range, 39-83 years) undergoing renal ablation procedures. This pilot included the quantification of recovery, pain, physical well-being, interference with social activities, and physical function as reported by the patient, including measures obtained from the National Institutes of Health's Patient-Reported Outcome Measurement Information System (PROMIS). Such measures were obtained within 24 hours before ablation and days 1-7 and 30 after ablation. RESULTS: The mean numeric rating (0-10) pain scores at 1 and 2 days after treatment were 1.8 (SD, 2.3) and 2.6 (SD, 2.5). Similarly, mean scores for both overall physical well-being and social activities declined by less than 2 points in the days after ablation. PROMIS scales for physical function and social activities showed very little change from baseline. Nearly 50% of patients thought that they had completely recovered from the ablation on the day after treatment; this perception of recovery declined at days 3-5 and then increased to 89% at 30 days after ablation. CONCLUSION: This pilot study shows the feasibility of capturing patient-reported outcomes after renal ablation. Such information, particularly when collected from a broader patient population, will be valuable in providing a means to measure quality in the ablation practice and in improving patient education regarding treatment.

Development and Validation of a Patient-Reported Outcome Measurement for Symptom Assessment in Cirrhotic Ascites.

OBJECTIVES: As current treatments of cirrhotic ascites are not associated with survival benefit, symptom relief is the major therapeutic end point. We developed a questionnaire (Ascites-Q; modified polycystic liver disease questionnaire) and assessed validity and responsiveness for symptom assessment in cirrhotic ascites. METHODS: Ascites-Q was compared with Functional Assessment of Chronic Illness Therapy-Ascites Index (FACIT-AI; developed for malignant ascites) and Japanese Ascites Symptom Inventory-7 (ASI-7) in cirrhotics undergoing large-volume paracentesis. Convergent validity was defined as correlation >0.4 between ascites questionnaires and quality of life (QoL) visual analog scale. Responsiveness was assessed by comparing scores at baseline and 7 days after large-volume paracentesis. To test discriminative ability, we compared scores of patients with cirrhotic controls without ascites (n=24) and diuretic-sensitive ascites (n=46). RESULTS: We included 90 patients with refractory cirrhotic ascites (61% male, mean age 59 years, Model of End-Stage Liver Disease (MELD) score 16, median paracentesis volume 4,100 ml). Higher symptoms scores were correlated with lower QoL (Ascites-Q: r=0.479, P<0.001, FACIT-AI: r=0.313, P=0.007; ASI-7: r=0.340, P=0.004), but only Ascites-Q showed convergent validity (r>0.4). Symptoms decreased after paracentesis (Ascites-Q: 57 to 34, FACIT-AI: 44 to 33, and ASI-7: 57 to 25, all P<0.001). Ascites-Q and ASI-7 discriminated between controls without ascites, diuretic-sensitive, and refractory ascites (Ascites-Q: 16 vs. 35 vs. 56 points, ASI-7: 2 vs. 25 vs. 61 points, all P<0.05), whereas FACIT-AI (39 vs. 40 vs. 52 points) could not (P=0.314). Ascites-Q was validated at 3 months in an independent cohort with ascites controlled with a pump. CONCLUSIONS: The Ascites-Q is the best ascites-specific outcome to evaluate symptom relief in cirrhotic ascites.

Diagnostic performance of unenhanced computed tomography and 18 F-fluorodeoxyglucose positron emission tomography in indeterminate adrenal tumours.

OBJECTIVE: Evidence on the diagnostic performance of adrenal imaging is limited. We aimed to assess the diagnostic performance of unenhanced computed tomography (CT) and 18 F-fluorodeoxyglucose (18 FDG) positron emission tomography (PET)/CT imaging in a high-risk population for adrenal malignancy using an optimal reference standard. DESIGN: Retrospective cohort study. METHODS: Imaging studies of patients with adrenal nodules who underwent adrenal biopsy and/or adrenalectomy between 1994 and 2014 were reviewed and compared to the reference standard of histology. Eighty % of patients presented with known or suspected extra-adrenal malignancy. RESULTS: Unenhanced abdominal CT was performed in 353 patients with adrenal lesions; median size was 3 (0.7-15) cm and median radiodensity was 33 (-21-78) Hounsfield units (HU). Radiodensity of >10 HU diagnosed malignancy with a sensitivity of 100%, specificity of 33%, positive predictive value (PPV) of 72% and negative predictive value (NPV) of 100%. 18 FDG-PET/CT was performed in 89 patients; median tumour size was 2.1 (0.7-9.2) cm. Maximum standardized uptake (SUV max) was higher in malignant lesions when compared to benign lesions (median=10 [2.3-29.4] vs 3.7 [1.4-24.5], respectively, P<.0001). Similarly, median SUV max lesion to SUV max liver ratio (ALR) in malignant lesions was higher than in benign lesions (median=3 [0.74-13.4] vs 1.2 [0.5-6.6], respectively, P<.0001). 18 FDG-PET/CT ALR >1.8 diagnosed malignancy with a sensitivity of 87%, specificity of 84%, PPV of 85% and NPV of 86%. CONCLUSION: Noncontract CT radiodensity of ≤10 HU excludes malignancy even in a high-risk population. For indeterminate adrenal lesions, given a superior specificity, 18 FDG-PET/CT could be considered as a second stage imaging study.

Synchronous nephron-sparing approaches for bilateral renal masses: peri-operative and renal functional outcomes.

OBJECTIVES: To evaluate the peri-operative and renal functional outcomes of patients undergoing synchronous bilateral partial nephrectomy (PN) or percutaneous cryoablation (PCA). PATIENTS AND METHODS: We retrospectively reviewed our institutional nephrectomy and renal mass ablation registries to identify all patients with synchronous bilateral renal masses who underwent simultaneous bilateral PN (n = 76) or PCA (n = 13) between 1974 and 2013. Changes in estimated glomerular filtration rate (eGFR) as well as peri-operative complications are descriptively reported for each procedure. RESULTS: The number of treated renal masses in the 76 patients in the PN group and the 13 patients in the PCA group was 249 and 28, respectively. The median (interquartile range [IQR]) age at treatment was 62 (50, 71) years for the PN group and 67 (56, 72) for the PCA group. The median (IQR) maximum tumour sizes were 4.6 (3.4, 6.5) cm and 2.6 (2.4, 3.2) cm for the PN and PCA groups, respectively. The median (IQR) length of hospital stay was 7 (5, 8) days for the PN group and 1 (1, 10) days for the PCA group. The median (IQR) change in eGFR from baseline to discharge was -32 (-46, -15)% for the PN group and -17% (-33, -3) for the PCA group. By 3 months, median (IQR) renal function improved, with changes of -9 (-19, 0)% and -8 (-11, 15)%, respectively, compared with baseline. No patient in either group required renal replacement therapy in the peri-operative period. Early postoperative complications (within 30 days) occurred in 16 patients (21.6%) in the PN and four patients in the PCA group. In particular, angioembolization for bleeding was required in the postoperative period in two patients (2.7%) in the PN and one patient in the PCA group. CONCLUSIONS: Our experience suggests that synchronous bilateral PN or PCA are feasible treatment options for select patients presenting with bilateral renal masses. In select cases, both approaches appear to have reasonable rates of peri-operative complications and effects on renal function.

A Comparison of Bleeding Complications in Patients Undergoing Percutaneous Renal Cryoablation Using Cryoprobes with and without Heat-Based Track Ablation.

PURPOSE: To determine if the use of heat-based track ablation with new-generation cryoprobes is associated with decreased renal cryoablation bleeding complications. MATERIALS AND METHODS: Eighty-nine patients who underwent percutaneous cryoablation for treatment of a solitary renal mass with the use of cryoprobes with track ablation (CwTA) from October 29, 2015, to May 18, 2017, were compared with a propensity score-matched control group of 178 patients who underwent treatment with the use of cryoprobes without track ablation (Cw/oTA) from January 5, 2012, to October 28, 2015. Bleeding complications were assessed with the use of the Clavien-Dindo classification system and compared between the matched patient groups by means of conditional logistic regression, both univariately and in a multivariate model to adjust for imbalanced covariates. Change in patient hemoglobin was evaluated as a secondary measure of periprocedural bleeding. RESULTS: Seven of the 89 patients (7.9%) who underwent percutaneous renal cryoablation with the use of CwTA developed major (grade ≥3) bleeding complications, versus 13 of the 178 patients (7.3%) treated with the use of Cw/oTA. Conditional logistic regression analysis adjusted for potential confounders showed that major, minor, and overall bleeding complications were not associated with the type of cryoprobes used for treatment (P values .727, .370, and .733, respectively). There was also no significant difference in postprocedural change in hemoglobin for patients treated with the use of CwTA compared with Cw/oTA (P = .909). Furthermore, total duration of track ablation in patients with bleeding complications (mean 169 seconds, SD 68, range 60-240) was not significantly different than in patients without bleeding complications (mean 171 seconds, SD 86, range 30-360; P = .940). CONCLUSIONS: The use of cryoprobes with heat-based track ablation did not decrease the incidence of bleeding complications after renal cryoablation compared with procedures performed without track ablation.

Percutaneous Cryoablation of Solitary, Sporadic Renal Cell Carcinoma: Outcome Analysis Based on Clear-Cell versus Papillary Subtypes.

PURPOSE: To evaluate treatment outcomes with percutaneous cryoablation (PCA) based on renal cell carcinoma (RCC) histology. METHODS AND MATERIALS: Patients treated with PCA for a solitary, sporadic stage T1a RCC from 2003 to 2016 were identified from a single institution's renal ablation registry. Patients with multiple tumors, history of RCC, or genetic syndromes associated with RCC (n = 60); no specific RCC subtype determined from core biopsy (n = 66); RCC subtype other than clear-cell or papillary (n = 7); or less than 3 mo of follow-up imaging (n = 5) were excluded. In total, 173 patients met study inclusion criteria. Oncologic outcomes, clinical outcomes, and complications were evaluated based on tumor subtype. RESULTS: Of the 173 patients who underwent PCA for a stage T1a RCC, 130 (75%) had clear-cell RCC (ccRCC) and 43 (25%) had papillary RCC (pRCC). Median tumor size was 2.9 cm (range, 1.3-4.0 cm). Technically successful cryoablation was achieved in all 173 patients. Local tumor recurrence developed in 6 patients with ccRCC (4.6%), new renal tumors developed in 1 patient (0.8%), and metastatic RCC developed in 1 patient (0.8%) who also had local tumor recurrence. No patients with pRCC showed local tumor recurrence, new renal tumors, or metastatic disease. The 5-year disease-free survival rate in patients with ccRCC was 88%, compared with 100% in patients with pRCC (P = .48). Nine patients (5.2%), all with ccRCC, experienced major complications (P = .11). CONCLUSIONS: Percutaneous ablation is a viable treatment option for patients with clinical stage T1a pRCC and ccRCC. Percutaneous ablation may be a very favorable treatment strategy particularly for pRCC.

Introduction of Microwave Ablation Into a Renal Ablation Practice: Valuable Lessons Learned.

OBJECTIVE: The purpose of this study was to evaluate the early outcomes of percutaneous microwave ablation (MWA) for clinical stage T1 (cT1) renal masses when performed within a high-volume ablation practice with critical emphasis on procedural safety. MATERIALS AND METHODS: A retrospective review of a percutaneous renal ablation registry identified 26 patients with a total of 27 cT1 renal masses treated with MWA between 2011 and 2017. Mean patient age was 63.8 years and 16 (61.5%) patients were male. Mean renal mass size ± SD was 2.3 ± 0.8 cm (range, 1.1-4.7 cm). The main outcome parameters investigated were technical success, local tumor progression, survival rates, and complications. Complications were categorized using the Clavien-Dindo classification system. Rates of local progression-free and cancer-specific survival (PFS and CSS, respectively) were estimated using the Kaplan-Meier method. RESULTS: Technical success was 100% on contrast-enhanced CT or MRI performed immediately after renal MWA. Twenty-four patients (92%) with 25 tumors had follow-up imaging for 3 months or longer (mean, 20.6 ± 11.6 months), with no local tumor recurrences identified. Estimated 3-year local PFS and CSS were 96% and 94%, respectively. The overall complication rate was 19.2%; two patients (7.7%) experienced minor complications (grade I or II) and three patients (11.5%) experienced major bleeding or urinary-related complications (grade III or higher), including one death. CONCLUSION: This study suggests that percutaneous MWA is a promising minimally invasive treatment option for cT1 renal masses. Nonetheless, major bleeding and urinary-related complications can occur, and further studies are needed to determine optimal patient and tumor selection for renal MWA.

Anaphylactic reaction to an ultrasound contrast agent (Lumason) in a patient with systemic mastocytosis.

Severe adverse reactions to ultrasound (US) contrast agents are rare, and only a few cases of anaphylaxis following the administration of US contrast agents have been reported, often without a defined etiology. We present a case of anaphylactic reaction to the injection of an US contrast agent in a patient with systemic mastocytosis, which highlights the disorder as a possible risk factor warranting additional consideration prior to performing a contrast-enhanced US examination.

Endogenous Heat-Shock Protein Induction with or Without Radiofrequency Ablation or Cryoablation in Patients with Stage IV Melanoma.

LESSONS LEARNED: Percutaneous thermal ablation combined with in situ granulocyte-macrophage colony-stimulating factor cytokine therapy was technically feasible and well tolerated.No significant clinical or immunologic responses were seen. BACKGROUND: Melanoma tumor-derived heat-shock proteins (HSPs) and HSP-peptide complexes can elicit protective antitumor responses. The granulocyte-macrophage colony-stimulating factor (GM-CSF) chemokine can also promote uptake and processing by professional antigen presenting cells (APCs). On this basis, we designed a pilot study of percutaneous thermal ablation as a means to induce heat-shock protein vaccination plus GM-CSF to determine safety and preliminary antitumor activity of this combination. MATERIALS AND METHODS: This study was designed to assess overall safety of percutaneous ablation combined with GM-CSF for unresectable, metastatic melanoma including uveal and mucosal types. All patients received heat-shock therapy (42°C for 30 minutes), then received one of three treatments: (a) intralesional GM-CSF (500 mcg standard dose); (b) radiofrequency ablation (RFA) + GM-CSF; or (c) cryoablation plus GM-CSF. The primary endpoint of the study was the induction of endogenous HSP70 and melanoma-specific cytotoxic T lymphocytes (CTL). RESULTS: Nine patients (three per study arm) were enrolled. No dose-limiting toxicity was observed as specified per protocol. All patients developed progressive disease and went on to receive alternative therapy. Median overall survival (OS) was 8.2 months (95% confidence interval [CI] 2-17.2). The study was not powered to detect a difference in clinical outcome among treatment groups. CONCLUSION: Percutaneous thermal ablation plus GM-CSF was well tolerated, technically feasible, and demonstrated an acceptable adverse event profile comparable to conventional RFA and cryoablation. While HSP70 was induced following therapy, the degree of HSP70 elevation was not associated with clinical outcome or induced CTL responses. While percutaneous thermal ablation plus GM-CSF combinations including checkpoint inhibitors could be considered in future studies, the use of GM-CSF remains experimental and for use in the context of clinical trials.