Precision pain management in interventional radiology.

Pain is a common manifestation of several benign and malignant conditions. Inadequate response to conservative therapies is often succeeded by incremental use of analgesics and opioids; however, such an approach is often ineffective, not well tolerated by patients, and carries the risk of addiction leading to the opioid crisis. Implementing minimally invasive percutaneous procedures, performed by interventional radiologists has proven to be successful in providing safe, effective, and patient-specific therapies across a wide range of painful conditions. In the present narrative review, we will review the repertoire of minimally invasive imaging guided interventions, which have been successfully used to treat common painful benign and malignant conditions. We briefly describe each technique, common indications, and expected results.

The Impact of COVID-19 on Interventional Radiology Practice Worldwide: Results from a Global Survey.

BACKGROUND: The COVID-19 pandemic had an unprecedented impact on clinical practice and healthcare professionals. We aimed to assess how interventional radiology services (IR services) were impacted by the pandemic and describe adaptations to services and working patterns across the first two waves. METHODS: An anonymous six-part survey created using an online service was distributed as a single-use web link to 7125 members of the Cardiovascular and Interventional Radiological Society of Europe via email. Out of 450 respondents, 327 who completed the survey at least partially including 278 who completed the full survey were included into the analysis. RESULTS: Interventional radiologists (IRs) reported that the overall workload decreased a lot (18%) or mildly (36%) or remained stable (29%), and research activities were often delayed (30% in most/all projects, 33% in some projects). Extreme concerns about the health of families, patients and general public were reported by 43%, 34% and 40%, respectively, and 29% reported having experienced significant stress (25% quite a bit; 23% somewhat). Compared to the first wave, significant differences were seen regarding changes to working patterns, effect on emergency work, outpatient and day-case services in the second wave. A total of 59% of respondents felt that their organisation was better prepared for a third wave. A total of 19% and 39% reported that the changes implemented would be continued or potentially continued on a long-term basis. CONCLUSION: While the COVID-19 pandemic has negatively affected IR services in terms of workload, research activity and emotional burden, IRs seem to have improved the own perception of adaptation and preparation for further waves of the pandemic.

Pain relief and local tumour control following percutaneous image-guided cryoablation for spine metastasis: a 12-year single-centre experience.

AIM: To assess pain relief and local tumour control retrospectively in spinal metastases undergoing cryoablation. MATERIALS AND METHODS: Between May 2008 and September 2020, 46 metastases in 41 consecutive patients (mean age 59.7±4.4 [SD] years; range 27-84) were treated with cryoablation in 42 interventional sessions. Patient demographics, procedural data, complications, pain, and local tumour control were analysed retrospectively. RESULTS: Thirty-one patients (36 spine metastases; 32 sessions) were treated for pain relief and 10 (10 metastases; 10 sessions) for local tumour control. Clinical success was reached in 30/32 (93.8%) interventional palliative sessions. Mean pre-procedural numerical pain rate scale was 6.2±1.7 (SD), and dropped significantly to 3.5±1.8 (SD), 1.9±1.7 (SD), and 1.9±1.8 (SD) at 24-h, 1-month and at the last available follow-up (median 16.5±23.2 [SD] months), respectively. For patients requiring local tumour control, primary clinical success was reached in 6/10 (60%) spinal metastases at median 25-months follow-up. The overall complication rate was 8%, with no secondary fractures or iatrogenic thermal-mediated nerve injuries reported. CONCLUSION: Percutaneous image-guided cryoablation of spinal metastases is safe and effective in achieving pain relief and local tumour control.

Spinal metastases treated with bipolar radiofrequency ablation with increased (>70°C) target temperature: Pain management and local tumor control.

PURPOSE: To investigate the safety and clinical efficacy of bipolar radiofrequency ablation (b-RFA) with increased (>70°C) target temperature for the treatment of spine metastases with the intent of achieving pain relief or local tumor control. MATERIALS AND METHODS: Thirty-one patients with a total of 37 metastases who were treated with b-RFA with increased temperature and vertebroplasty from January 2016 to May 2019 were retrospectively included. There were 20 women and 11 men with a mean age of 62.4±10.5 (SD) years (range: 40-78years). Patients and metastases characteristics, procedure details and clinical outcomes were analyzed. RESULTS: Metastases were predominantly located in lumbar (22/37; 59.5%) or thoracic spine (13/37; 35.1%). Mean target temperature was 88.4±3.5 (SD) °C (range: 70-90°C). Technical success was 100% (37/37 metastases). One (1/37; 2.7%) major complication unrelated to b-RFA was reported. One (1/37; 2.7%) metastasis was lost to follow-up. Favorable outcome was noted in patients receiving b-RFA for pain management (16/20 metastases; 80%; mean follow-up, 3.4±2.9 [SD] months) or with oligometastatic/oligoprogressive disease (6/6 metastases; 100%; mean follow-up, 5.0±4.6 [SD] months). In patients receiving b-RFA to prevent complications, favorable outcome was noted in 6/10 metastases (60%; mean follow-up, 3.8±4.8 [SD] months). CONCLUSIONS: B-RFA with increased target temperature has an excellent safety profile and results in high rates of pain relief and local metastasis control in patients with oligometastatic/oligoprogressive disease. Suboptimal results are achieved in patients receiving b-RFA to prevent complications related to the growth of the index tumor.

Percutaneous image-guided double oblique anterior approach to the acetabulum for cementoplasty.

AIM: To report the technique of percutaneous double oblique anterior access to the acetabulum and evaluate its feasibility and safety. MATERIALS AND METHODS: Pelvic computed tomography (CT) examinations of 60 patients (30 men and 30 women; mean age 62.6±13.2 years) were retrieved randomly from the picture archiving and communication system (PACS). A virtual intraosseous trajectory was defined on both sides on the axial CT images with the entry point marked 1 cm above the anterosuperior iliac spine and the endpoint defined just above the level of the ischial spine at the midpoint of the posterior acetabulum. Patient age, sagittal oblique angulation, axial oblique angulation, length of intraosseous trajectory, distance from the hip joint, thickness of the iliac bone cortex, and intervening structure(s) between the skin and the bone entry points were recorded. RESULTS: The mean sagittal and axial oblique angulations were 34.2±4.5° and 31.5±6.7°, respectively, and mean length of the intraosseous trajectory was 11.8±0.9 cm. The axial oblique angle and length of the intraosseous trajectory were significantly lower in the female than the male population (p<0.05). None of the virtual trajectories traversed the hip joint. In 112/120 trajectories (93.3%), there were no cortical breaches in the iliac bones. In eight trajectories in four patients, the virtual trajectory crossed either the medial iliac cortex (4/120; 3.3%) or the medial iliac cortex and the iliacus muscle (4/120; 3.3%). CONCLUSION: The anterosuperior iliac and ischial spines can be used safely and reliably as landmarks to perform the double oblique anterior approach.

Osteoid osteoma in older adults: clinical success rate of percutaneous image-guided thermal ablation.

AIM: To assess the clinical success rate of percutaneous radiofrequency and laser ablation of osteoid osteomas in older adults. MATERIALS AND METHODS: Percutaneous radiofrequency or laser ablation was performed in 43 patients (35 years and older) with osteoid osteoma to achieve definitive cure in this retrospective study. The clinical success rate was defined as complete pain relief determined by numeric rating scale (NRS) scores (pre-procedural and post-procedural at 1-week, 6-week, and 2-year intervals). Tumour characteristics, technical success, procedural details, biopsy results, and complications were documented. RESULTS: Forty-four osteoid osteomas were ablated in 43 patients, and all procedures were technically successful. The clinical success rates were 95.2% (41/43), 93% (40/43), and 93.2% (41/44) at 1-week, 6-week, and 2-year post-procedural intervals. The acute complication rate was 2.3% (1/44; meningeal perforation following epidural anaesthesia). No delayed complication was documented. CONCLUSION: Osteoid osteomas are not unique to the paediatric and young population, and safe and effective definitive treatment of these benign tumours in older adults can be achieved by percutaneous radiofrequency and laser ablation with excellent patient outcomes.

[Percutaneous MR-guided prostate cancer cryoablation: Predictive factors and oncologic outcomes]. / Cryothérapie totale de la prostate sous IRM par voie périnéale : résultats carcinologiques et facteurs prédictifs.

OBJECTIVE: To determine the pejorative predictive factors on oncologic outcomes of percutaneous MR-guided whole gland prostate cancer cryoablation (CA). METHODS: Medical records of patients treated from 2009 to 2012, to assess medium-term oncologic outcomes, were reviewed. Prostate biopsies were performed in local recurrence suspicion (biochemical failure, MR follow-up failure). RESULTS: Among 18 patients, mean age of 72.6 (61-78), 2 (11 %) and 7 (38.9 %) biological and reported biopsy-proven local recurrence respectively with our initial technic of CA. Mean follow-up and recurrence were 56.3 (±21.7) and 20.7 (±13.9) months respectively. A previous treatment of prostate cancer (P=0.5), pre-treatment PSA (P=0.2), pre-treatment Gleason/ISUP score (P=0.4), nadir PSA post-CA (P=0.22) were not associated with recurrence. Bilateral positive cores appears as a pejorative predictive factor (P=0.04). However mean pre-treatment positive cores percentage, 25 (±16.5) in responding patients versus 40.7 (±25.2) in case of recurrence, and maximum percentage of cancer extent in each positive core, 10.6 (±9.3) in responding patients versus 18.7 (±16.5) in case of recurrence, seemed associated with local recurrence after prostate CA but our analysis wasn't able to find a difference (P=0.09 and P=0.3 respectively) due to a lack of power. CONCLUSION: Bilateral positive cores appears as a pejorative predictive factor. In our experience, important tumor volume seem to be a pejorative predictive factor for oncologic outcomes after PCA whereas treatment, PSA, Gleason/ISUP score, nadir PSA are not. LEVEL OF EVIDENCE: 4.

Transforaminal Insertion of a Thermocouple on the Posterior Vertebral Wall Combined with Hydrodissection during Lumbar Spinal Radiofrequency Ablation.

The purpose of the present article is to describe the technique of transforaminal insertion of an ultrathin thermosensor in the anterior epidural space in 13 patients treated by radiofrequency ablation. The mean time taken to position the thermosensor was 10.6 minutes (range, 5-38 minutes). Technical success was 93% (correct positioning in 13/14 levels). Additional hydrodissection was performed through the same access in 11 cases. No postoperative neural deficit was elicited in any of the cases.

Percutaneous extra-spinal cementoplasty in patients with cancer: A systematic review of procedural details and clinical outcomes.

PURPOSE: To perform a systematic review of technical details and clinical outcomes of percutaneous extra-spinal cementoplasty in patients with malignant lesions. MATERIALS AND METHODS: PUBMED, MEDLINE, MEDLINE in-process, EMBASE and the Cochrane databases were searched between January 1990 and February 2019 using the keywords «percutaneous cementoplasty¼, «percutaneous osteoplasty¼ and «extra-spinal cementoplasty¼. Inclusion criteria were: retrospective/prospective cohort with more than 4 patients, published in English language, reporting the use of percutaneous injection of cement inside an extra-spinal bone malignant tumour using a dedicated bone trocar, as a stand-alone procedure or in combination with another percutaneous intervention, in order to provide pain palliation and/or bone consolidation. RESULTS: Thirty articles involving 652 patients with a total of 761 lesions were reviewed. Mean size of lesion was 45mm (range of mean size among publications: 29-73mm); 489 lesions were located in the pelvis, 262 in the long bones of the limbs and 10 in other locations. Cementoplasty was reported as a stand-alone procedure for 60.1% of lesions, and combined with thermal ablation for 26.2% of lesions, implant devices for 12.3% of lesions, and balloon kyphoplasty for 1.4% of lesions. The mean volume of injected cement was 8.8mL (range of mean volume among publications: 2.7-32.2mL). The preoperative visual analogic scores ranged between 3.2 and 9.5. Postoperative scores at last available follow-up ranged from 0.4 to 5.6. Thirteen papers reported a reduction of the visual analogic scores of 5 points or more. Nerve injury was the most frequent symptomatic leakage (0.6%). CONCLUSION: Percutaneous extra-spinal cementopasty is predominantly performed as a stand-alone procedure and for lesions in the bony pelvis. It appears to be an effective tool to manage pain associated with malignant bone tumours. There is however a lack of standardization of the technique among the different publications.

Preclinical evaluation of the atraumatic nature of a spring loaded blunt tip coaxial needle in a swine model.

PURPOSE: To test in vivo in an animal model the inherent atraumatic characteristics of the spring loaded blunt tip of a coaxial needle (Gangi-SoftGuard®, Apriomed, Sweden) against a conventional sharp stylet coaxial needle. MATERIAL AND METHODS: The study was conducted on a 40kg male swine that was its own control for a vascular trauma model. The procedure consisted of voluntary attempts to transfix and traverse the artery/aorta under continuous real-time angiogram. Test and control needles were positioned in the region of the intercostal, superior mesenteric and femoral/deep femoral arteries, and in the aorta. Computed tomography (CT) angiogram was performed post trauma to check for bleeding in the form of extravasation of contrast material. One attempt was performed per site and needle, except for the intercostal artery where a second attempt was done with the test needle, resulting in a total of 4 and 5 tests for the control and test needles, respectively. RESULTS: With the spring loaded blunt tip, no vascular trauma or bleeding was noted in the intercostal, superior mesenteric and femoral arteries, nor in the aorta. Vascular spasm that recovered with time was noted during the second attempt to transfix the same intercostal artery. There were consistent vascular traumas and bleedings with the control needle in all three tested arteries and the aorta, confirmed on angiogram as well as CT angiogram. CONCLUSION: The atraumatic feature offered by the spring loaded blunt tip prevented vascular trauma during the 5 attempts made to transfix the artery/aorta in a swine.

Safety of percutaneous renal cryoablation: an international multicentre experience from the EuRECA retrospective percutaneous database.

OBJECTIVE: To investigate the safety profile of percutaneous cryoablation of renal tumours < 7 cm, utilising data extracted from an international multicentre registry. MATERIALS AND METHODS: A retrospective review of all immediate and delayed complications from a multicentre database was performed and was categorised according to the Clavien-Dindo classification. Statistical analysis was performed for both overall complications (all Clavien-Dindo) and major complications (Clavien-Dindo 3 to 5). The following criteria were identified as potential predictive factors for complications: centre number, modality of image guidance, tumour size (≤ 4 cm vs. > 4 cm), number of tumours treated in the same session (1 vs. > 1) and tumour histology. RESULTS: A total of 713 renal tumours underwent ablation in 647 individual sessions. In 596 of the cases, one tumour was treated; in the remaining 51 cases, several tumours were treated per session. Mean lesion size was 2.8 cm. Fifty-four complications (Clavien-Dindo 1 to 5) occurred as a result of the 647 procedures, corresponding to an overall complication rate of 8.3%. The most frequent complication was bleeding (3.2%), with 9 cases (1.4%) requiring subsequent treatment. The rate of major complication was 3.4%. The only statistically significant prognostic factor for a major complication was a tumour size > 4 cm. CONCLUSION: Percutaneous renal cryoablation is associated with a low rate of complications. Tumours measuring more than 4 cm are associated with a higher risk of major complications. KEY POINTS: • Percutaneous kidney cryoablation has a low rate of complications. • Bleeding is the most frequent complication. • A tumour size superior to 4 cm is a predictive factor of major complication.

[Percutaneous renal ablation: Pre-, per-, post-interventional evaluation modalities and adapted management]. / Traitement ablatif pour cancer du rein : modalités d'évaluation pré-, per-, post-intervention et prise en charge adaptée.

OBJECTIVES: Ablative treatment (AT) rise is foreseen, validation of steps to insure good proceedings is needed. By looking over the process of the patient, this study evaluates the requirements and choices needed in every step of the management. METHODS: We searched MEDLINE®, Embase®, using (MeSH) words and we looked for all the studies. Investigators graded the strength of evidence in terms of methodology, language and relevance. RESULTS: Explanations of AT proposal rather than partial nephrectomy or surveillance have to be discussed in a consultation shared by urologist and interventional radiologist. Per-procedure choices depend on predictable ballistic difficulties. High volume, proximity of the hilum or of a risky organ are in favor of general anesthesia, cryotherapy and computed tomography/magnetic resonance imaging (CT/MRI). Percutaneous approach should be privileged, as it seems as effective as the laparoscopic approach. Early and delayed complications have to be treated both by urologist and radiologist. Surveillance by CT/MRI insure of the lack of contrast-enhanced in the treated area. Patients and tumors criteria, in case of incomplete treatment or recurrence, are the key of the appropriate treatment: surgery, second session of AT, surveillance. CONCLUSION: AT treatments require patient's comprehension, excellent coordination of the partnership between urologist and radiologist and relevant choices during intervention.

[Image-guided tumor ablation]. / Techniques d'ablation tumorale.

INTRODUCTION: Ablatives techniques for destroying in situ a tumoral process aim tissular necrosis by the application of several physical principles. MATERIAL AND METHODS: We searched MEDLINE®, Embase®, using (MeSH) words; from January 2005 through May 2017, and we looked for all the studies. Investigators graded the strength of evidence in terms of methodology, language and relevance. RESULTS: Forty-seven articles were analyzed. We described ablative techniques and sorted them in thermal and non-thermal therapies according to the used physical principle and their frequency of use in the urological pathology. CONCLUSION: Percutaneous ablative therapies are mini-invasive techniques, which have an important role in tumors focal treatment. This article is a review of the ablative therapies and describes their physical principles, their equipment and their recent technological modifications, which have been developed to improve the clinical success of these techniques.

Expanding the borders: Image-guided procedures for the treatment of musculoskeletal tumors.

Interventional radiology has revolutionized the local management of bone tumours, offering new minimal invasive alternatives to surgery and radiotherapy. Its role has continuously increased over the past years for the treatment of benign tumors and also of some malignant ones, especially in palliative situations. The development of protective techniques and new ablative technologies, such as cryoablation, contributes to expand the role of the interventional radiologist to new fields of applications in musculoskeletal oncology.

Temperature monitoring during microwave ablation in ex vivo porcine livers.

OBJECTIVE: The aim of the present study was to assess the temperature map and its reproducibility while applying two different MWA systems (915 MHz vs 2.45 GHz) in ex vivo porcine livers. MATERIALS AND METHODS: Fifteen fresh pig livers were treated using the two antennae at three different settings: treatment time of 10 min and power of 45 W for both systems; 4 min and 100 W for the 2.45 GHz system. Trends of temperature were recorded during all procedures by means of fiber optic-based probes located at five fixed distances from the antenna, ranging between 10 mm and 30 mm. Each trial was repeated twice to assess the reproducibility of temperature distribution. RESULTS: Temperature as function of distance from the antenna can be modeled by a decreasing exponential trend. At the same settings, temperature obtained with the 2.45 GHz system was higher than that obtained with the 915 MHz thus resulting into a wider area of ablation (diameter 17 mm vs 15 mm). Both systems showed good reproducibility in terms of temperature distribution (root mean squared difference for both systems ranged between 2.8 °C and 3.4 °C). CONCLUSIONS: When both MWA systems are applied, a decreasing exponential model can predict the temperature map. The 2.45 GHz antenna causes higher temperatures as compared to the 915 MHz thus, resulting into larger areas of ablation. Both systems showed good reproducibility although better results were achieved with the 2.45 GHz antenna.

Over ten years of single-institution experience in percutaneous image-guided treatment of bone metastases from differentiated thyroid cancer.

OBJECTIVE: Percutaneous image-guided treatments (PIGT) are performed by interventional radiologists with a minimally invasive approach. Currently, very little published data on their outcomes are available and conclusions regarding their application are cautious. The aim of the present study was to review our experience in PIGT of bone metastases from thyroid cancer. MATERIALS AND METHODS: Institutional databases were reviewed to identify patients with differentiated thyroid cancer and bone metastases who received PIGT between October 2001 and April 2014. Complications, local evolution of the treated lesions, and overall survival (OS) were investigated. RESULTS: Twenty-five patients (12 male, 13 female) underwent 49 PIGT sessions consisting of cementoplasty (77.5%), cryoablation (14.3%) or radiofrequency ablation (8.2%). Most of the treated lesions (50/54, 92.6%) were symptomatic at the time of PIGT. Median follow-up after PIGT was 4.6 years. Local complete remission rate was 55.6%. Two complications (one major and one minor) were noted, but none of these were consistent with fractures or nervous system injuries. OS after PIGT was 71.6%, 66.8% and 60.1% at 1, 2 and 3 years, respectively. A difference in survival was observed between patients with metastatic bone involvement only at the time of first PIGT compared to those with multi-organ involvement (P = 0.03). CONCLUSIONS: Patients with bone metastases from differentiated thyroid cancer may benefit from PIGT. Although patients are usually referred for PIGT due to their symptomatic status, a more relevant "curative" role may exist for PIGT. Further prospective studies are needed to confirm this perception.

Interventional Radiologist's perspective on the management of bone metastatic disease.

Bone metastases can be treated by interventional radiologists with a minimally invasive approach. Such treatments are performed percutaneously under radiological imaging guidance. Different interventional techniques can be applied with curative or palliative intent depending on lesions and patients' status. In the whole, available interventional techniques are distinguished into "ablative" and "consolidative". Ablative techniques achieve bone tumor necrosis by dramatically increasing or decreasing intra-tumoral temperature. This option can be performed in order to alleviate pain or to eradicate the lesion. On the other hand, consolidative techniques aim at obtaining bone defect reinforcement mainly to alleviate pain and prevent pathological fractures. We herein present evidence supporting the application of each different interventional technique, as well as common strategies followed by interventional radiologists while approaching bone metastases.

Stature of caucasian elderly estimated by scapula length from chest X-ray.

Stature is an important biological characteristic considered in the clinical activities. Height (h)is frequently hard to measure in the elderly population or in people with skeletal deformities and vertebral fractures. Furthermore it represents also a key point in forensic evaluations. Our aim was to provide an equation in order to predict human height based on the Longitudinal Scapular Diameter(LSD) measured through a Chest X-ray (CX) in an elderly Italian population. We enrolled 60 patients (age > 65 years) who underwent a standard CX. An average LSD was obtained on the basis of the measurements of left and right scapula. Stature was measured in standard conditions by a calibrated stadiometer in all patients. A linear predictive model was employed to estimate stature by LSD. The predictive equation for stature estimation [cm] from LSD [cm] was: h=2.969*LSD+116.7. The linear regression was significant (p <; 0.01) and the correlation coefficient was 0.75. In order to assess the performance of the proposed model, we compared our results with the values obtained in the same population with a largely employed approach, i.e., the Chumlea's method. Considering the whole population, the mean error using LSD equation was 4.4 cm vs 4.6 cm from Chumlea's. The proposed linear relationship between human height and LSD measured by CX can be considered valid in elderly patients, showing comparable results to the Chumlea's method.