Pneumodissection for skin protection in image-guided cryoablation of superficial musculoskeletal tumours.

PURPOSE: Pneumodissection is described as a simple method for preventing skin injury during cryoablation of superficial musculoskeletal tumours. METHODS: Superficial tumour cryoablations performed from 2009 to 2015 were retrospectively reviewed. Pneumodissection was performed in 13 patients when the shortest tumour-skin distance was less than 25 mm. Indications were pain palliation (n = 9) and local tumour control (n = 4). Patients, target tumours, technical characteristics and complications up to 60 days post ablation were reviewed. The ice ball-skin distances with and without pneumodissection were compared by a paired t-test and further assessed for association with covariates using ANCOVA. RESULTS: Technical success for ablation was 12 of 13. The mean shortest tumour-skin distance was 15.0 mm (3.2-24.5 mm). The mean thickness of pneumodissection was 9.6 mm (5.2-16.6 mm) resulting in mean elevation of skin of 3.4 mm (1.2-5.3 mm). Mean shortest ice ball-skin distance after pneumodissection was 10.5 mm (4.2-19.7 mm). No infection or systemic air embolism was noted. No intraprocedural frostbite was observed. CONCLUSION: Pneumodissection is feasible, effective and safe in protecting the skin during image-guided cryoablation of superficial tumours. KEY POINTS: • Frostbite during image-guided cryoablation of superficial tumours is commonly under-reported. • Frostbites are painful and may introduce infection into the superficial ablation zone. • Warm compress, saline and CO 2 have shortcomings in protecting the skin. • Pneumodissection is free, readily available, easy to use and safe and effective.

T cell activation threshold regulated by E3 ubiquitin ligase Cbl-b determines fate of inducible regulatory T cells.

E3 ubiquitin ligase Casitas-B-lineage lymphoma protein-b (Cbl-b) is critical for establishing the threshold for T cell activation and is essential for induction of T cell anergy. Recent studies suggest that Cbl-b is involved in the development of CD4(+)CD25(+) inducible regulatory T cells (iTregs). In this study, we report that the optimal induction of Foxp3 by naive CD4(+)CD25(-) T cells requires suboptimal TCR triggering. In the absence of Cbl-b, the TCR strength for optimal Foxp3 induction is downregulated in vitro. Using TCR-transgenic Rag(-/-) mice in combination with Cbl-b deficiency, we show that in vivo iTreg development is also controlled by Cbl-b via tuning the TCR strength. Furthermore, we show that Akt-2 but not Akt-1 regulates Foxp3 expression downstream of Cbl-b. Therefore, we demonstrate that Cbl-b regulates the fate of iTregs via controlling the threshold for T cell activation.