The COVID-19 pandemic and its effects on follow-up of patients with early breast cancer: A patient survey.

PURPOSE: Despite limited evidence supporting its effectiveness, most guidelines recommend long-term, routinely scheduled in-person surveillance of patients with early breast cancer (EBC). The COVID-19 pandemic led to increased use of virtual care. This survey evaluated patient perspectives on follow-up care. METHODS: Patients with EBC undergoing surveillance were surveyed about follow-up protocols, perceptions, and interest in clinical trials assessing different follow-up strategies. RESULTS: Of 402 approached patients 270 completed the survey (response rate 67%). Median age 62.5 years (range 25-86) and median time since breast cancer diagnosis was 3.8 years (range < 1-33 years). Most (n = 148/244, 60%) were followed by more than one provider. Routine follow-ups with breast examination were mostly conducted by medical/radiation oncologists every 6 months (n = 110/236, 46%) or annually (n = 106/236, 44%). Participants felt routine follow-up was useful to monitor for recurrence, manage side effects of cancer treatment and to provide support/reassurance. Most participants felt regular follow-up care would detect recurrent cancer earlier (n = 214/255, 96%) and increase survival (n = 218/249, 88%). The COVID-19 pandemic reduced the number of in-person visits for 54% of patients (n = 63/117). Patients were concerned this reduction of in-person visits would lead to later detection of both local (n = 29/63, 46%) and distant recurrences (n = 25/63, 40%). While many felt their medical and radiation oncologists were the most suited to provide follow-up care, 55% felt comfortable having their primary care provider (PCP) conduct surveillance. When presented with a scenario where follow-up has no effect on earlier detection or survival, 70% of patients still wanted routine in-person follow-up for reassurance (63%) with the goal of earlier recurrence detection (56%). CONCLUSIONS: Despite limited evidence of effectiveness of routine in-person assessment, patients continue to place importance on regularly scheduled in-person follow-up.

Percutaneous image-guided cryoablation with temporary balloon occlusion of the renal artery for the treatment of central renal tumors.

PURPOSE: The purpose of this study was to report the technical feasibility and outcomes of percutaneous image-guided cryoablation with temporary balloon occlusion of the renal artery for the treatment of central renal tumors. MATERIALS AND METHODS: All consecutive patients with central renal tumors treated with cryoablation and temporary renal artery occlusion from January 2017 to October 2021 were retrospectively included. Patient demographics, tumor's characteristics, procedural data, technical success, primary and secondary clinical efficacy, complications (according to Cardiovascular and Interventional Radiology Society of Europe [CIRSE] classification) and follow-up were investigated. RESULTS: A total of 14 patients (8 men, 6 women; mean age 72.4 years ± 21.4 [SD] years; age range: 42-93 years) with 14 central renal tumors (median size, 32 mm; IQR: 23.5, 39.5 mm; range: 13-50 mm) were treated with percutaneous image-guided cryoablation and temporary balloon occlusion of the renal artery. Technical success was 13/14 (93%), with 1/14 (7%) failure of vascular access. A median of 4 cryoprobes (IQR: 3, 4.75) were inserted and protective hydrodissection was performed in 11/14 (79%) patients. Median time to perform cryoprobes insertion, hydrodissection and vascular access was 26.5 min (IQR: 18, 35 min), 10 min (IQR: 10, 17 min) and 30 min (IQR: 20, 45 min) respectively. Median duration of the whole intervention was 150 min (IQR: 129, 180 min; range: 100-270 min). Median hospital stay was 2.5 days (IQR: 2, 4 days; range: 2-14 days). Major complications occurred in 3/14 (21%) patients. Primary efficacy rate was 93% (13/14 patients). Median oncological follow-up was 25 months (IQR: 11, 33 months; range: 6-39 months). One patient experienced renal tumor recurrence at 14-months of follow-up, which was successfully treated with repeat cryoablation. CONCLUSION: Percutaneous image-guided cryoablation of renal tumors with temporary balloon occlusion of the renal artery is technically feasible, with a high technical success rate and paths the way for percutaneous treatment of central renal tumors.

Safety and Efficacy of Percutaneous Cryoablation of Extraspinal Thyroid Cancer Bone Metastases with Curative Intent: Single-Center Experience with a Median Follow-up of More than 5 Years.

PURPOSE: To determine the oncologic outcomes and safety profile of image-guided percutaneous cryoablation (PCA) for extraspinal thyroid cancer bone metastases with curative intent. MATERIALS AND METHODS: Between January 2010 and January 2020, 16 consecutive patients (8 men, 8 women; mean age, 61 years ± 19; range, 30-84 years) with 18 bone metastases (median bone tumor size, 19 mm; interquartile range [IQR], 12-29 mm; range, 7-58 mm) underwent PCA of oligometastatic extraspinal bone metastases. Thirteen (81%) patients were radioiodine therapy resistant. Two patients underwent 2 bone tumor ablations in a single session. Procedural data, oncologic outcomes, follow-up (with magnetic resonance imaging and positron emission tomography-computed tomography), and adverse events were retrospectively investigated. Local tumor progression-free survival, disease-free survival, and overall survival were estimated using the Kaplan-Meier method. RESULTS: A median of 2 cryoprobes (IQR, 1.25-3 cryoprobes; range, 1-7 cryoprobes) were used, with 2 freezing cycles; the median length of freezing was 20 minutes (IQR, 17-20 minutes; range, 10-20 minutes). The technical success was 100% (18/18), and the primary technical efficacy was 94.4% (17/18). The median follow-up was 68 months (IQR, 38-93 months). During follow-up, 3 of 17 (17.6%) tumors demonstrated local progression at 7, 13, and 27 months. Consequently, the 1-, 2-, 3-, 4-, and 5-year local tumor progression-free survivals were 93.3%, 84.6%, 76.9%, 75%, and 72.7%, respectively. Two of 16 (12.5%) patients died during follow-up at 43 and 88 months. The major adverse event rate was 5.5% (1/18) with 1 postablative acromion fracture. CONCLUSIONS: PCA for extraspinal thyroid cancer bone metastases demonstrated high local tumor control rates with a safe profile at long-term follow-up.

De-escalating adjuvant therapies in older patients with lower risk estrogen receptor-positive breast cancer treated with breast-conserving surgery: A systematic review and meta-analysis.

PURPOSE: Radiation therapy (RT) and endocrine therapy (ET) are standard treatments for hormone receptor-positive (HR+) breast cancer after breast-conserving surgery (BCS). However, many older patients are at greater risk of treatment-related toxicities and non-cancer related death, and less likely to benefit from these standard treatments. A systematic review was performed evaluating outcomes of omitting RT or ET in older patients aged ≥50 treated with BCS for lower-risk breast cancer. METHODS: Medline, Embase, and the Cochrane Register of Controlled Trials were queried from 1980 to April 30th, 2020 for randomized controlled studies (RCTs) and prospective cohort studies (PCSs) evaluating omission of RT and/or ET compared to RT plus ET in patients. Meta-analysis was performed using random-effects models with findings reported as risk ratios (RR) with 95% confidence intervals (CI). RESULTS: From 3860 citations, 10 prospective studies met eligibility criteria. Omission of RT alone was evaluated in 7 RCTs (n = 4604) and one PCS (n = 667); omission of ET alone was assessed in 1 PCS (n = 271); and omission of either ET or RT was compared to ET plus RT in 1 RCT (n = 495). Adjuvant RT compared to no RT reduced 5- and 10-year in-breast tumor recurrence [5-year: RR 0.16, 95 %CI 0.09-0.27 l 10-year: 0.28, 95 %CI 0.16-0.5], but had no effect on survival [5-year: RR 0.94, 95 %CI 0.77-1.15; 10-year: 1.01, 95 %CI 0.9-1.12]. CONCLUSION: The current body of evidence suggests that RT can be omitted in older patients with lower-risk disease. However, more trials on the omission of ET are required to better inform treatment decisions.

Percutaneous cryoablation for advanced and refractory extra-abdominal desmoid tumors.

PURPOSE: To assess efficacy and safety of percutaneous cryoablation (CA) for advanced and refractory extra-abdominal desmoid tumors. MATERIALS AND METHODS: This retrospective study reviewed 30 consecutive patients with symptomatic desmoid tumors evolving after "wait and watch" periods, and despite medical treatment, treated by CA between 2007 and 2019. Progression free survival (PFS), objective response rate, pain reduction (decreased of visual analogic scale pain (VAS)[Formula: see text] 3 or disappearance of pain), total volume lesion (TVL) and complications were documented. Kaplan Meier method was used to outline PFS. Paired sample t test was used to compare volume of tumors before treatment and at 1 and 3 year. RESULTS: With a median follow-up of 18.5 months (range 6-93 months, interquartile range (IQR): 12-55), the PFS was 85.1% at 1 year and 77.3% at 3 years. Objective response was obtained for 80% of patients with a complete response for 43% patients. Pain reduction was obtained for 96.7% (95% confidence interval (95% CI): 90.3, 100) of patients. Median volume of desmoid tumor before treatment was 124.1cm3 (range 2-1727cm3, IQR: 54-338cm3). Median change of TLV after ablation was 66.6% (95% CI: 37.2, 72.3; p = 0.002) at 1 year and 76.4% (95% CI: 59.1, 89.8; p = 0.002) at 3 year. Adverse events rate was 36.6%, the most common was edema and temporary increase of pain in the days following CA. Four patients experienced a major complication (13.3%): 2 skin necrosis, 1 infection and 1 brachial plexopathy. CONCLUSION: CA is an effective treatment for advanced and refractory extra-abdominal desmoid tumor, that induces durable responses.

Can we rely on surgical clips placed during oncoplastic breast surgery to accurately delineate the tumor bed for targeted breast radiotherapy?

PURPOSE: Oncoplastic breast surgery (OBS) is gaining popularity among surgeons for breast-conserving surgery treatments. OBS relies on complex relocation and deformation of breast tissue involving the tumor bed (TB). In this study, we investigate the validity of using surgical clips with OBS for accurate TB delineation in adjuvant, targeted breast radiotherapy. METHODS: Different OBS techniques were simulated on realistic breast phantoms. Surgical clips were used to demarcate the TB. Following tumor resection and closure, the true TB (TBTrue) was extracted. Each phantom was CT imaged at several phases of surgery in order to record pre- and post-OBS closure surgical clip displacements. Two senior radiation oncologists (ROs) were asked to delineate TBs on CTs by relying on surgical clips placed as per standard protocol, and by referring to operative notes. Their original contours, as well as those expanded using 5-15 mm margins, were compared with the accurate TBTrue using the dice similarity coefficient (DSC), Hausdorff Distance (HD), and over- and under-contoured volumes. Inter- and intra-RO contour agreements were also evaluated. RESULTS: Post-OBS surgical clips were significantly displaced outside the original breast quadrant. Inter- and Intra-RO TB contours were consistent, yet systematically differed from TBTrue (DSC values range = 0.38 to 0.69, and maximum HD range = 17.8 mm to 38.0 mm). Using expansion margins did not improve contour congruence and caused significant over-contoured volumes. CONCLUSION: Following OBS, surgical clips alone are not reliable radiographic surrogates of TB locations and accurate TB delineation is challenging. For complex OBS cases, indication of any type of partial breast irradiation is very questionable.

Complications of percutaneous image-guided screw fixation: An analysis of 94 consecutive patients.

PURPOSE: The purpose of this study was to retrospectively assess the safety profile of percutaneous image-guided screw fixation (PIGSF) for insufficiency, impending or pathological fractures. MATERIALS AND METHODS: From July 2012 to April 2020, all consecutive patients who underwent PIGSF were retrospectively included in the study. Patient characteristics, fracture type, procedural data and complications were analyzed. Complications were divided into per-procedural, early (<24hours) and delayed (>24hours) and classified into minor (grade 1-2) and major complications (grade 3-5) according to Common Terminology Criteria for Adverse Events (CTCAE) v5.0. RESULTS: A total of 110 fractures (40 insufficiency [36%], 53 pathological [48.5%] and 17 impending [15.5%] fractures) in 94 patients (48 women, 46 men; mean age, 62.7±12.7 [SD] years; age range: 32-88 years) were treated with PIGSF during 95 procedures. Twenty-four-hours follow-up was available for all patients, and>24-hours follow-up was available for 79 (79/110; 71.8%) fractures in 69 (69/94; 73.4%) patients. Per-procedural complications occurred in 3/110 fractures (2.7%, all minor). Early complications were reported in 4/110 fractures (3.6%, 1 major and 3 minor) and delayed ones in 14/79 fractures (17.7%, 5 major and 9 minor). The most frequent major delayed complication was infection (3/79; 3.8%). CONCLUSION: The rate of per-procedural and early (within 24hours) complications following PIGSF is extremely low with most complications being minor, with major complications being delayed ones (>24hours).

Percutaneous hydrodissection for thermoprotection during cryoablation of periureteric and pyeloureteric junction renal cell carcinomas.

OBJECTIVE: To report our experience of percutaneous image-guided cryoablation of renal tumors located within 10 mm of the pyeloureteric junction (PUJ) and/or ureter, with hydrodissection as a stand-alone thermoprotective technique. MATERIALS AND METHODS: All patients who were offered combined hydrodissection and cryoablation of the PUJ/ureter to treat stage-1 renal cell carcinoma were retrospectively reviewed. Data regarding patients, lesions, and outcomes were collected. RESULTS: Twenty tumors in 20 patients (13 males:7 females) with a mean age of 74.4 ± 7.5 were included. Mean tumor size was 27.6 ± 6.4 mm. Nearby vulnerable structure(s) were identified as the ureter in 5/20 cases, the PUJ in 8/20 cases and both the PUJ and the ureter in the remaining 7/20 cases (35%) cases. Mean minimal distance between the tumor and the vulnerable organ(s) was 4.8 ± 2.6 mm (range 0-10). A mean of 1.7 ± 0.6 spinal needles were used per intervention with a mean time to complete hydrodissection of 18.6 ± 13.4 min. Primary and secondary technical efficacy rates were 90% and 95%, respectively. Mean follow-up was 23.1 ± 9.2 months. There were no immediate or delayed complications, in particular no urothelial strictures. Two tumor recurrences occurred during follow-up, with a time to disease progression of 13 and 31 months, respectively. CONCLUSION: hydrodissection of the PUJ/ureter to prevent thermal injury during cryoablation is an effective technique and does not seem to compromise the efficacy of ablation at short or mid-term follow-up.

Dose-sparing effect of deep inspiration breath hold technique on coronary artery and left ventricle segments in treatment of breast cancer.

BACKGROUND AND PURPOSE: The risk of radiation-induced cardiac injury remains a challenging problem in the treatment of breast cancer. Certain cardiac structures receive higher doses than others, which results in variable frequencies of radiation-induced injuries across these structures. Radiation dose can be reduced using the deep inspiration breath hold (DIBH) technique. We aimed to investigate the dose reductions from DIBH in individual cardiac segments. MATERIALS AND METHODS: A dosimetric analysis was performed on left-sided breast cancer patients who underwent breast-conserving surgery and whole breast irradiation. Radiation doses to the cardiac structures were compared between the DIBH and free-breathing (FB) techniques and the dose reductions with DIBH were correlated to the lung expansion. RESULTS: For the 75 patients included in our study, DIBH effectively reduced doses to the heart, left lung, left anterior descending coronary artery (LAD) and left ventricle (LV), but the degree of dose reductions was variable across different structures. The absolute dose reductions were greatest in the distal LAD (14.4 Gy) and apical LV (12.1 Gy) segments, compared with the other LAD (middle 9.7 Gy, proximal 1.6 Gy) and LV (anterior 5.3 Gy, lateral 2.9 Gy, septal 2.0 Gy, inferior 0.2 Gy) segments. Left lung expansion was significantly correlated with the dose reductions in the LAD (Spearman's rank correlation coefficient, ρ, 0.304) and LV (ρ, 0.420) segments. CONCLUSIONS: Our study demonstrates the dose-sparing effects of DIBH in various cardiac structures, especially the distal LAD and apical LV segments. The large dose reductions seen in the distal LAD and apical LV segments could potentially translate into clinical benefit of reduced cardiac toxicity, as these structures have been previously shown to receive the highest doses and are associated with radiation-induced injury.

Biomechanics of the Osseous Pelvis and Its Implication for Consolidative Treatments in Interventional Oncology.

The osseous pelvis is a frequent site of metastases. Alteration of bone integrity may lead to pain but also to functional disability and pathological fractures. Percutaneous image-guided minimally invasive procedures, such as cementoplasty and screw fixation, have emerged as a viable option to provide bone reinforcement and fracture fixation, as stand-alone or combined techniques. Understanding the biomechanics of the osseous pelvis is paramount to tailor the treatment to the clinical situation. The purpose of the present review is to present the biomechanics of the osseous pelvis and discuss its implication for the choice of the optimal consolidative treatment.

Hydrodissection of the Retro-Sternal Space to Protect the Pericardium During Sternal Cryoablation.

PURPOSE: To report the retro-sternal space hydrodissection technique used to displace the heart and the pericardium posteriorly for thermoprotection ahead of sternal cryoablation (CA). METHODS AND MATERIALS: Between May 2015 and March 2020, hydrodissection of the retro-sternal space was performed in 5 consecutive patients (5 female; mean age 55.2 ± 9.3 years, range 41-65) who underwent percutaneous image-guided cryoablation of the sternum. The number of needles required, the implemented approach, volume of injectate to achieve hydrodissection, hydrodissection procedure time, distance between the lesion and the pericardium before and after hydrodissection, distance between the ice-ball and the pericardium, technical success and complications were retrospectively assessed. RESULTS: Technical success, defined as the completion of a full dual freeze protocol without contact between the ice-ball and the pericardium, was achieved in all cases (5/5, 100%). One to two needles were used to perform hydrodissection via a perpendicular (3/5) or an anterior oblique approach (2/5) and a mean hydrodissection procedure time of 10.4 ± 2.6 min (range 8-14). Minimum distance between the lesion and the pericardium increased from mean 5.8 ± 3.8 mm (range 0-10) before hydrodissection to a mean 22.2 ± 5.8 mm (range 18-32) after, with a mean distance between the final ice-ball and the pericardium of 11.6 ± 8.7 mm (range 7-27). A mean of 198 ± 79.8 mL (range 90-290) of iodinated contrast was injected. There were no immediate, short- or medium-term complication noted. CONCLUSION: Hydrodissection of the retro-sternal space is a feasible technique for sternal cryoablation in order to protect the pericardium from freezing for sternal cryoablation.

Performance of a New Blunt-Tip Needle for the Displacement of Critical Structure in Thermal Ablation.

PURPOSE: To ascertain the performance of a new blunt-tip needle (HydroGuard®), which allows injection of fluids during needle advancement in order to safely approach, displace and insulate nearby critical structures during thermal ablation (TA). MATERIALS AND METHODS: This study included 27 consecutive patients treated by TA [cryoablation (CA), radiofrequency (RFA), and microwave MWA)] between April 2018 and January 2019. During TA, hydro- or gas dissection was performed with HydroGuard® needle to displace and protect critical structures close to the tumor (< 10 mm). Technical and clinical success, distance between critical structure and tumor before and after hydro/gas dissection and complications were recorded. RESULTS: Eighteen patients were treated by CA (66.7%), 7 by MWA (25.9%) and 2 by RFA (7.4%). Majority of patients were treated with a curative intent (24/27; 88.8%). Adjacent critical structures include vessels (n = 3), nerves (n = 10), ureter/renal pelvis (n = 3), bowel/rectum (n = 10), stomach: (n = 3), diaphragm (n = 2), and pleura (n = 1). Technical success was 100%. Clinical success was 88% (24/27). Median minimum distance to adjacent critical structures before hydro/gas dissection was 1 mm (range 0-9 mm; IQR: 0-3 mm) versus 10.5 mm (range 4-47 mm; IQR: 9.7-18 mm) after displacement. Of the 27 patients treated, four developed complications (14.8%; 95% CI: 1.4-28.2): 1 major (3.7%; 95% CI: 0-10.8) and 3 minors (11.1%; 95% CI: 0-23). Only one minor complication was related to inadequate hydro-dissection, resulting in close proximity of the critical structure to the ablation zone. CONCLUSION: HydroGuard® is a safe and effective needle when used to approach, displace and insulate nearby critical structures during TA.

Hypofractionated radiotherapy for elderly breast cancer patients: from early stages disease to local palliation for unresectable disease.

There is a lack of clear guidelines on optimal radiotherapy dose regimen for elderly breast cancer patients. This review summarizes the current evidence on role of hypofractionated radiotherapy in elderly breast cancer. Also, suggestions have been provided on the best fractionation approaches based on current evidence. Hypofractionated radiotherapy is feasible and well tolerated in elderly breast cancer patients with both early and locally advanced disease. Ultra-hypofractionated regimen seem appropriate for palliation of unresectable primary breast disease and could become a safe approach for adjuvant treatments. Hypofractionated radiotherapy should be considered for treatment of elderly breast cancer for curative intent, as well as for palliation.

Radiological, dosimetric and mechanical properties of a deformable breast phantom for radiation therapy and surgical applications.

The displacement of tumor bed walls during oncoplastic breast surgery (OBS) decreases the accuracy of using surgical clips as the sole surrogate for tumor bed location. This highlights the need for better communication of OBS techniques to radiation oncologists. To facilitate OBS practice and investigate clip placement reliability, a realistic silicone-based breast phantom was constructed with components emulating a breast parenchyma, epidermis, areola, nipple, chest wall, and a tumor. OBS was performed on the phantom and surgical clips were placed to mark the tumor bed. The phantom was imaged with CT, MRI, and ultrasound (US). The parenchyma's signal-to-noise ratio (SNR) and clips to parenchyma's contrast-to-noise ratio (CNR) were measured. The phantom's CT Hounsfield Unit (HU), relative electron density (RED), and mass density were determined. 6 and 10 MV photon beam attenuation measurements were performed in phantom material. The Young's Modulus and ultimate tensile strength (UTS) of the phantom parenchyma and epidermis were measured. Results showed that the breast phantom components were visible on all imaging modalities with adequate SNR and CNR. The phantom's HU is 130 ± 10. The RED is 0.983. Its mass density is 1.01 ± 0.01 g cm-3. Photon attenuation measurements in phantom material were within 1% of those in water. The Young's Moduli were 13.4 ± 4.2 kPa (mechanical) and 30.2 ± 4.1 kPa (US elastography) for the phantom parenchyma. The UTS' were 0.05 ± 0.01 MPa (parenchyma) and 0.23 ± 0.12 MPa (epidermis). We conclude that the phantom's imaging characteristics resemble a fibroglandular breast's and allow clear visualization of high-density markers used in radiation therapy. The phantom material is suitable for dose measurements in MV photon beams. Mechanical results confirmed the phantom's similarity to breast tissue. The phantom enables investigation of surgical clip displacements pre- and post-OBS, and is useful for radiation therapy quality assurance applications.

[Percutaneous tumor ablation]. / Destruction tumorale percutanée.

Percutaneous tumor ablation has faced a major growth in recent years with progressive expansion of clinical indications and subsequent adoption by national and international guidelines. Such techniques have become popular due to their minimally invasive profile and precise image-guided targeting resulting into a significant decrease of the procedure-related morbidity. Traditionally, malignant, and to lesser extent benign tumors, have been treated with these new techniques in several different organs including liver, kidney, lung and bone. More recently, other anatomic districts/organs including thyroid, breast, uterus and soft tissues have also been treated. Nevertheless, in order to optimize clinical results, precise knowledge of physical principles underlying these new techniques is of paramount importance, since technical adjustments may be provided according to specific tissue features (e.g. vascularization, density, etc.) and clinical indications of the procedure. Therefore, the goal of this review article is to present all the available ablation techniques with particular regard to their underlying physical principles and most common clinical indications.

Efficacy of the Vertebral Body Stenting System for the Restoration of Vertebral Height in Acute Traumatic Compression Fractures in a Non-osteoporotic Population.

INTRODUCTION: To evaluate the effectiveness of percutaneous image-guided vertebral body stenting (VBS) at restoring vertebral height in acute, stable, traumatic thoracolumbar fractures in a young, non-osteoporotic population. MATERIALS AND METHODS: A single-centre retrospective review of all traumatic non-osteoporotic fractures treated with VBS between 2010 and 2017 was performed. Inclusion criteria included patients with recent (< 10 days), symptomatic and stable thoracolumbar compression fractures. Patients with low-energy fractures, osteoporosis and age > 60/50 years (male/female) were excluded. Primary outcomes included: correction of vertebral height, correction of kyphosis angle and Beck Index on reconstructed pre- and post-procedural CBCT images. Secondary outcomes included intra-procedural stent recoil, complications, cement leakage and factors predicting height restoration. RESULTS: Thirty-nine patients (26 men, 13 women; mean age 33.6 years, range 15-57 years) underwent VBS 5 days post-trauma on average (range 1-10), for stable compression fractures located between T5 and L5. Mean vertebral height gain, vertebral kyphosis angle correction and Beck index improvement were 3.8 mm (95% CI 3.36-4.50; P(> 3 mm) = 99.9%), 4.3° (95% CI 3.50-5.20; P(> 3°) = 99.9%) and 0.07 [95% CI 0.053-0.11], respectively (all statistically significant). Technical success was 92%, with 3 "major" stent recoils resulting in loss of vertebral height correction. No symptomatic complications were observed. No predictive factors for procedural success were identified. CONCLUSION: VBS can significantly restore vertebral height in young patients with traumatic vertebral compression fractures.

Hydrodissection of the Gallbladder Bed: A Technique for Ablations Located Close to the Gallbladder.

OBJECTIVE: To report the technique of hydrodissection of the gallbladder bed, in order to separate the gallbladder wall from the liver surface during microwave ablation of liver malignancies located in segment V. MATERIALS AND METHODS: Between January 2018 and March 2018, percutaneous hydrodissection of the gallbladder fossa was performed during four microwave ablation procedures in three patients (One patient was treated twice for the same lesion, making a total of four procedures for three lesions.) All treated lesions were located in segment V and abutting the gallbladder. Number of hydrodissection needles, volume of hydrodissection, repartition of hydrodissection, separation of tumour from the gallbladder post-hydrodissection, technical success of hydrodissection/ablation, and complications were recorded and evaluated. RESULTS: Hydrodissection of the gallbladder fossa was technically feasible in all four procedures, and microwave ablation was performed at maximum power without any early interruption. Time to perform hydrodissection was 11.3 min on average (range 7-18 min). Minimal distance between the ablation area and the GB increased from virtual to 10 mm on average (range 6-13), with a mean volume of dissection of 65 ml (range 40-100). Technical success was 75%. There was no complication related to the hydrodissection itself, and no acute or delayed gallbladder complication. CONCLUSION: Hydrodissection of the gallbladder bed is a feasible technique to separate the gallbladder from the liver surface. This could potentially decrease the risk of thermal injuries to the gallbladder wall when ablating tumours located in segment V.

Complications of Percutaneous Bone Tumor Cryoablation: A 10-year Experience.

Background Percutaneous cryoablation has been shown to be effective in the management of painful bone tumors. However, knowledge of the complication rate and risk factors for complication is currently lacking. Purpose To report the complication rate and associated risk factors for bone tumor cryoablation. Materials and Methods This retrospective study reviewed complications in 239 consecutive patients (131 men and 108 women; median age, 64 years; age range, 6-86 years) who underwent cryoablation of 320 primary or metastatic bone tumors between January 2008 and November 2017. Common Terminology Criteria for Adverse Events was used to categorize complications as major (grade 3-4) or minor (grade 1-2). Multivariable analysis was performed for variables with P values less than .20, including age, tumor location, adjacent critical structures, number of cryoprobes, and Eastern Cooperative Oncology Group performance status (ECOG-PS). Results Among the 320 tumors, the total complication rate was 9.1% (29 of 320; 95% confidence interval [CI]: 6%, 12.2%). The major complication rate was 2.5% (eight of 320; 95% CI: 0.8%, 4.2%), with secondary fracture the most frequent complication (1.2% [four of 320]; mean delay, 71 days); cryoablation site infection, tumor seeding, bleeding, and severe hypotension were each observed in 0.3% (one of 320) of procedures. Minor complications included postprocedural pain (2.2% [seven of 320]), peripheral neuropathy (0.9% [three of 320]), and temporary paresthesia (0.9% [three of 320]). For all complications, associated risk factors included ECOG-PS greater than 2 (odds ratio [OR], 3.1 [95% CI: 3, 7.6]; P = .01), long-bone cryoablation (OR, 17.8 [95% CI: 2.3, 136.3]; P = .01), and use of more than three cryoprobes (OR, 2.5 [95% CI: 1.0, 6.0]; P = .04); for major complications, associated risk factors included age greater than 70 years (OR, 7.1 [95% CI: 1.6, 31.7]; P = .01) and use of more than three cryoprobes (OR, 23.6 [95% CI: 2.8, 199.0]; P = .01). Conclusion Bone tumor cryoablation is safe, with a 2.5% rate of major complications, most commonly secondary fracture (1.2%). Major complications are associated with age greater than 70 years and use of more than three cryoprobes. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Jennings in this issue.

Physician Survey of Timing of Adjuvant Endocrine Therapy Relative to Radiotherapy in Early Stage Breast Cancer Patients.

BACKGROUND: Patients can start endocrine therapy before, concurrently with, or sequentially after radiotherapy. The optimal timing of starting adjuvant endocrine therapy is unknown. This survey was performed to evaluate physician recommendations. METHODS: Canadian oncologists were surveyed to evaluate institutional and personal practices regarding the prescription of adjuvant endocrine therapy and radiotherapy. Perspectives regarding the design of a clinical trial to compare concurrent versus sequential therapy, and the optimum end points for such a trial, were also sought. RESULTS: The overall response rate was 30% (65/220), with responses mainly from medical (35/65, 54%) and radiation (28/65, 43%) oncologists. Eighty-four percent of respondents reported an absence of institutional protocols. The majority of physicians (57%, 36/65) identified endocrine therapy provided after radiotherapy as the preferred sequence of treatments. Twenty-two percent (14/65) had no preference, while 21%, (14/65) started endocrine therapy either before or concurrent with radiotherapy. Practice patterns were largely based on the physician's own clinical experience. Thirty-two percent of physicians (21/65) had concerns regarding concurrent endocrine therapy and radiotherapy, including increased adverse effects with endocrine therapy (13/21, 62%), reduced efficacy of radiotherapy (4/21, 19%), reduced compliance with endocrine therapy (3/21, 14%), and increased radiation toxicity (1/21, 5%). Most thought a pragmatic clinical trial addressing this question would help standardize and improve patient care. CONCLUSION: Decisions around the timing of endocrine therapy and radiotherapy are largely being made on the basis of physicians' personal choices. In the absence of data to support these decisions, appropriately powered trials are needed.

Hydrodissection of the Retrohepatic Space: A Technique to Physically Separate a Liver Tumour from the Inferior Vena Cava and the Ostia of the Hepatic Veins.

OBJECTIVE: To report a technique of percutaneous retrohepatic hydrodissection, highlighting its potential to physically separate liver tumours from the inferior vena cava (IVC) and the ostia of the hepatic veins (HV). MATERIALS AND METHODS: Between December 2017 and April 2018, hydrodissection of the retrohepatic IVC was performed in 5 patients (5 females; mean age 64.5 years) undergoing percutaneous ablation of 5 liver metastases (mean size: 3.6 cm) located adjacent to the IVC. Number of hydrodissection needles, volume of hydrodissection, separation of tumour/liver parenchyma from IVC/HV post-hydrodissection; technical success of ablation; and complications were tabulated. RESULTS: Two to three 22G spinal needles were required per case for adequate dissection. Mean volume to obtain sufficient hydrodissection was 410 ml on average. Physical separation of the IVC and tumour/hepatic parenchyma was successful in all cases, by 9 mm on average (range 5-12 mm). It also leaded to physical separation of the ostia of the right and middle HV in all cases. There was no early or delayed complication, notably no venous thrombosis in the post-operative period. All lesions but one were completely ablated after one session at 3-month follow-up. The patient with residual tumour was successfully retreated. CONCLUSION: Retrohepatic hydrodissection is a feasible technique to separate a tumour from the IVC and/or ostia of the HV. This could potentially limit the heat-sink effect/reduce the risk of thrombosis. Larger follow-up studies are required to assess efficacy on a long-term basis.