Thermal ablation for small renal masses: Identifying the most appropriate tumor size cut-off for predicting perioperative and oncological outcomes.

OBJECTIVES: To test TRIFECTA achievement [1) absence of CLAVIEN-DINDO ≥3 complications; 2) complete ablation; 3) absence of ≥30% decrease in eGFR] and local recurrence rates, according to tumor size, in patients treated with thermal ablation (TA: radiofrequency [RFA] and microwave ablation [MWA]) for small renal masses. METHODS: Retrospective analysis (2008-2020) of 432 patients treated with TA (RFA: 162 vs. MWA: 270). Tumor size was evaluated as: 1) continuously coded variable (cm); 2) tumor size strata (0.1-2 vs. 2.1-3 vs. 3.1-4 vs. >4 cm). Multivariable logistic regression models and a minimum P-value approach were used for testing TRIFECTA achievement. Kaplan-Meier plots depicted local recurrence rates over time. RESULTS: Overall, 162 (37.5%) vs. 140 (32.4%) vs. 82 (19.0%) vs. 48 (11.1%) patients harboured, respectively, 0.1 to 2 vs. 2.1 to 3 vs. 3.1 to 4 vs. >4 cm tumors. In multivariable logistic regression models, increasing tumor size was associated with higher rates of no TRIFECTA achievement (OR:1.11; P< 0.001). Using a minimum P-value approach, an optimal tumor size cut-off of 3.2 cm was identified (P< 0.001). In multivariable logistic regression models, 3.1 to 4 cm tumors (OR:1.27; P< 0.001) and >4 cm tumors (OR:1.49; P< 0.001), but not 2.1 to 3 cm tumors (OR:1.05; P= 0.3) were associated with higher rates of no TRIFECTA achievement, relative to 0.1 to 2 cm tumors. The same results were observed in separate analyses of RFA vs. MWA patients. After a median (IQR) follow-up time of 22 (12-44) months, 8 (4.9%), 8 (5.7%), 11 (13.4%), and 5 (10.4%) local recurrences were observed in tumors sized 0.1 to 2 vs. 2.1 to 3 vs. 3.1 to 4 vs. >4 cm, respectively (P= 0.01). CONCLUSION: A tumor size cut-off value of ≤3 cm is associated with higher rates of TRIFECTA achievement and lower rates of local recurrence over time in patients treated with TA for small renal masses.

Small-size (40 µm) Beads Loaded with Irinotecan in the Treatment of Patients with Colorectal Liver Metastases.

PURPOSE: The purpose of this study was to investigate survival outcomes and safety after chemoembolization using irinotecan-loaded small-size beads (DEB-IRI) in patients with colorectal liver metastases unresponsive to standard chemotherapy. MATERIALS AND METHODS: Between December 2013 and August 2019, fifty-five patients (32 males, median age 64.5 years) with pretreated colorectal liver metastases unresponsive to standard chemotherapy underwent 197 chemoembolization procedures (mean 3.6 ± 2.3 SD per patient). Thirty patients (30/55; 55%) had extrahepatic disease metastatic to the lungs, lymph nodes or peritoneum. Local tumor control was evaluated at 3, 6, 9 and 12 months. Median overall survival, survival rates at 1 and 2 year and adverse events were evaluated. RESULTS: Local tumor control was achieved in 32/55 (58%), 12/55 (22%), 4/55 (7%) and 2/55 (4%) patients at 3, 6, 9 and 12 months, respectively. Median overall survival was 9.9 months (95% CI: 6.2-14.2 months) with 1- and 2-year survival rates of 45% and 15%, respectively. A total of 30 (15%) G1-G3 treatment-related adverse events occurred across all embolization procedures. No severe treatment-related adverse events occurred. CONCLUSION: Chemoembolization using irinotecan-loaded small-size beads is a safe and effective procedure as a salvage treatment in patients with colorectal liver metastases, showing good results in terms of liver-specific progression free survival and overall survival.

Multi-institutional analysis of outcomes for thermosphere microwave ablation treatment of colorectal liver metastases: the SMAC study.

OBJECTIVES: Oligometastatic colorectal cancer benefits of locoregional treatments but data concerning microwave ablation (MWA) are limited and interactions with systemic therapy are still debated. The aim of this study is to evaluate safety and effectiveness of Thermosphere™ MWA (T-MWA) of colorectal liver metastases (CLM) and factors affecting local tumor progression-free survival (LTPFS). METHODS: In this multi-institutional retrospective study (January 2015-September 2019), patients who underwent T-MWA for CLM were enrolled. Complications according to SIR classification were collected, primary efficacy and LTP were calculated. Analyzed variables included CLM size at diagnosis and at ablation, CLM number, ablation margins, intra-segment progression, chemotherapy before ablation (CBA), variations in size (ΔSDIA-ABL), and velocity of size variation (VDIA-ABL) between CLM diagnosis and ablation. Uni/multivariate analyses were performed using mixed effects Cox model to account for the hierarchical structure of data, patient/lesions. RESULTS: One hundred thirty-two patients with 213 CLM were evaluated. Complications were reported in 6/150 procedures (4%); no biliary complications occurred. Primary efficacy was achieved in 204/213 CLM (95.7%). LTP occurred in 58/204 CLM (28.4%). Six-, twelve-, and eighteen-month LTPFS were 88.2%, 75.8%, and 69.9%, respectively. At multivariate analysis, CLM size at ablation (p = 0.00045), CLM number (p = 0.046), ablation margin < 5 mm (p = 0.0035), and intra-segment progression (p < 0.0001) were statistically significant for LTPFS. ΔSDIA-ABL (p = 0.63) and VDIA-ABL (p = 0.38) did not affect LTPFS. Ablation margins in the chemo-naïve group were larger than those in the CBA group (p < 0.0001). CONCLUSION: T-MWA is a safe and effective technology with adequate LTPFS rates. Intra-segment progression is significantly linked to LTPFS. CBA does not affect LTPFS. Anticipating ablation before chemotherapy may take the advantages of adequate tumor size with correct ablation margin planning. KEY POINTS: • Thermosphere™-Microwave ablation is a safe and effective treatment for colorectal liver metastases with no registered biliary complications in more than 200 ablations. • Metastases size at time of ablation, intra-segment progression, and minimal ablation margin < 5 mm were found statistically significant for local tumor progression-free survival. • Chemotherapy before ablation modifies kinetics growth of the lesions but deteriorates ablation margins and does not significantly impact local tumor progression-free survival.

Real-Time US-CT fusion imaging for guidance of thermal ablation in of renal tumors invisible or poorly visible with US: results in 97 cases.

PURPOSE: To assess the capability of ultrasound-computed tomography (US-CT) fusion imaging to guide a precise targeting of renal tumors invisible or poorly visible with US. MATERIALS AND METHODS: From 2016 renal tumors poorly visible or inconspicuous/invisible at US were treated at our institution with the guidance of US/CT fusion in a room equipped with CT scanner. Feasibility of the procedure, accuracy of targeting, complications, and technique efficacy were evaluated. RESULTS: Of 227 patients treated from 2016 to March 2020, 91 patients (65 males and 26 females, mean age 68.5 ± 10.1 years) with 97 renal lesions (mean maximum diameter 21.6 ± 9.4 mm) inconspicuous/invisible (29/97, 29.9%) or poorly visible (68/97, 70.1%) at US underwent treatment under US-CT fusion guidance. US-CT fusion imaging guidance was always technically feasible and enabled correct targeting in 97/97/(100%) of cases. Technical success was achieved in 93/97 lesions (95.9%). Three lesions were retreated during the same ablative session, while 1 was retreated in a subsequent session. Thus, primary efficacy was achieved in one session in 96/97 (98.9%) cases and secondary efficacy in 97/97 (100%) cases. CONCLUSION: US-CT image fusion guidance allows for a correct tumor targeting of renal tumors poorly visible or inconspicuous/invisible with US alone, with a high rate of technical success and technique efficacy.

Local recurrence of renal cell carcinoma successfully treated with fusion imaging-guided percutaneous thermal ablation.

Image-guided thermal ablations are increasingly applied in the treatment of renal cancers, under the guidance of ultrasound (US) or computed tomography (CT). Fusion imaging allows exploitation of the strengths of all imaging modalities simultaneously, eliminating or minimising the weaknesses of every single modality. We present a case of a 68-year-old patient treated using US/CT fusion imaging to guide radiofrequency ablation for local recurrence of renal cell carcinoma undetectable by ultrasound.

Image-guided thermal ablation of central renal tumors with retrograde cold pyeloperfusion technique: a monocentric experience.

Purpose: To evaluate feasibility, safety and efficacy of image-guided thermal ablations associated with retrograde pyeloperfusion in patients with centrally located renal tumors.Materials and methods: 48 patients (15 women, 33 men, mean age 69.1 ± 11.8) were treated with image-guided thermal ablation associated with pyeloperfusion for 58 centrally located renal tumors (mean diameter 32.3 ± 7.32 mm). 7 patients had a single kidney. Microwave and radiofrequency ablation were used. All treatments were performed with ultrasound, CT, or fusion imaging guidance under general anesthesia and simultaneous retrograde cold pyeloperfusion technique.Results: Procedure was feasible in all cases. Technical success and primary technical efficacy were reached in 51/58 (88%) and 45/54 tumors (83%). With a second ablation performed in 5 tumors, secondary technical efficacy was achieved in 50/50 (100%) tumors. Minor and major complications occurred in 8/58 (13%) and 5/58 (8%) tumors. No significative change in renal function occurred after treatment.During follow-up, 5 recurrences occurred, that were retreated with a second ablation. At last follow up (mean 32.2 ± 22.0 months), 41/48 (85%) treated patients were free from disease. The median TTP and PFS were 27.0 (range, 2.3-80.0) and 26.5 months (range, 2.3-80.0), respectively.Conclusion: Image-guided thermal ablation associated with protective pyeloperfusion is a feasible, safe, and effective treatment option for patients with central renal tumors with a minimal impact on renal function and relevant potential to avoid nephrectomy.

Endovascular Aspiration Thrombectomy in the Management of Kidney Ischemia: A Case Report.

Renal artery occlusion is a serious event that can result in significant impairment or loss of renal function, leading to dialysis dependency. The nonspecific signs and symptoms of its presentation frequently result in a delay in diagnosis, thus contributing to delay in treatment. We report the case of a 53-year old woman who suffered renal artery occlusion, in which the renal perfusion was restored after three days of ischemia, by endovascular aspiration thrombectomy.

Long-Term Follow-Up Outcomes after Percutaneous US/CT-Guided Radiofrequency Ablation for cT1a-b Renal Masses: Experience from Single High-Volume Referral Center.

Image-guided thermal ablations are increasingly applied in the treatment of renal cancers, under the guidance of ultrasound (US) or computed tomography (CT). Sometimes, multiple ablations are needed. The aim of the present study was to evaluate the long-term results in patients with renal mass treated with radiofrequency ablation (RFA) with both US and CT, with a focus on the multiple ablations rate. 149 patients (median age 67 years) underwent RFA from January 2008 to June 2015. Median tumor diameter was 25 mm (IQR 17-32 mm). Median follow-up was 54 months (IQR 44-68). 27 (18.1%) patients received multiple successful ablations, due to incomplete ablation (10 patients), local tumor progression (8 patients), distant tumor progression (4 patients) or multiple tumor foci (5 patients), with a primary and secondary technical efficacy of 100%. Complications occurred in 13 (8.7%) patients (6 grade A, 5 grade C, 2 grade D). 24 patients died during follow-up, all for causes unrelated to renal cancer. In conclusion, thermal ablations with the guidance of US and CT are safe and effective in the treatment of renal tumors in the long-term period, with a low rate of patients requiring multiple treatments over the course of their disease.

Spontaneous hepatic haemangioma rupture and hemoperitoneum: a double problem with a single stage interventional radiology solution.

Hepatic haemangioma is a congenital vascular malformation, considered the most common benign mesenchymal hepatic tumour. Spontaneous or traumatic rupture is the most severe complication. In case of rupture, surgical resection and enucleation, as a single therapy or after trans-arterial embolization are considered the treatments of choice. We report a case of spontaneous rupture of a hepatic haemangioma with massive hemoperitoneum successfully treated by percutaneous hepatic trans-arterial embolization and pelvic drainage alone.

Varicocele Due to Post-traumatic Arteriovenous Fistula.

Varicocele consists of abnormally dilated and tortuous veins within the pampiniform plexus, usually in the left scrotum. We reported a rare case of right varicocele due to post-traumatic arteriovenous fistula successfully treated by percutaneous embolization.