CT-Guided Celiac Ganglion Block for Neurogenic Gastrointestinal Dysmotility.

PURPOSE: To determine whether celiac ganglion block can serve as a diagnostic test for dysautonomia as the cause of gastrointestinal dysmotility-related symptoms. MATERIALS AND METHODS: This was an institutional review board-approved, prospective, single-arm, registered study, from January 2020 to May 2021, and included patients aged 14-85 years with gastrointestinal symptoms of food intolerance, abdominal pain, or angina. Patients with nonneurogenic causes (ie, chronic cholecystitis, peptic ulcer disease, gastroesophageal reflux, and malabsorption syndrome) were excluded. All 15 patients underwent computed tomography-guided celiac ganglion block with 100 mg of liposomal bupivacaine. Patients filled out the dysautonomia-validated questionnaire Composite Autonomic Symptom Score 31 (COMPASS-31) before and after intervention. Differences (before vs after) were compared with the exact permutation method. RESULTS: Fifteen women (median age, 17 years; range, 14-41 years) were included. Average COMPASS-31 score improved significantly, from baseline 11 (SD ± 2.8) to 4 (SD ± 1.9) (improvement, 7 points ± 2.8; P < .001). All patients reported significant reduction in abdominal angina. Fourteen of the 15 patients (93%) reported complete resolution, and 14 of 15 (93%) reported a significant reduction in non-postprandial abdominal pain (P < .01). Only 1 patient reported no improvement. Eight of those 14 patients (57%) reported complete resolution of abdominal pain. There was a significant improvement in functional scores (vomiting, P = .01; constipation frequency, P = .02; constipation severity, P < .01; and nausea, P < .01). The rate of minor and major adverse events was 13% and 0%, respectively, per the Society of Interventional Radiology adverse event classification. CONCLUSIONS: Celiac ganglion block is a safe diagnostic tool for confirming dysautonomia as the underlying condition in patients with gastrointestinal dysmotility-related symptoms. It could provide early diagnosis, lead to definitive treatment (ganglionectomy) earlier, or obviate unnecessary surgery.

Spontaneous breast hematoma as a complication of anticoagulation therapy requiring angiography and embolization.

Spontaneous breast hematoma is a rare complication of therapeutic anticoagulation therapy with few cases reported in the literature. We present a case of spontaneous breast hematoma resulting in hypotension and symptomatic anemia. Angiography demonstrated multiple sites of hemorrhage within the breast, which was treated with gelatin sponge embolization. This case highlights the role of interventional radiology in the treatment of breast hematoma, as well as reviews the arterial vascular anatomy of the breast.

Percutaneous Cryoablation for Stage 1 Renal Cell Carcinoma: Outcomes from a 10-year Prospective Study and Comparison with Matched Cohorts from the National Cancer Database.

Background Percutaneous cryoablation (PCA) is an increasingly utilized treatment for stage I renal cell carcinoma (RCC), albeit without supportive level I evidence. Purpose Primary objective was to determine the 10-year oncologic outcomes of PCA for stage I RCC in a prospective manner. Secondary objectives were to compare outcomes after partial nephrectomy (PN) and radical nephrectomy (RN) from the National Cancer Database (NCDB), to determine long-term renal function, and to determine the risk of metachronous disease. Materials and Methods In this institutional review board-approved prospective observational study (2006-2013), study participants with single, sporadic, biopsy-proven RCC were included to calculate the 10-year overall survival, recurrence-free survival, and disease-specific survival after PCA. Results were compared with matched PN and RN NCDB cohorts. Overall and recurrence-free survival probabilities were estimated by using nonparametric maximum likelihood estimator. Disease-specific survival was estimated by using the redistribution-to-right method. Age at diagnosis was stratified as a risk for survival. The effect on estimated glomerular filtration rate, serum creatinine level, and the risk for hemodialysis and metachronous disease were calculated. Results One hundred thirty-four patients (46% men) with single, sporadic, biopsy-proven RCC (median size ± standard deviation, 2.8 cm ± 1.4) were included. Overall survival was 86% (95% confidence interval [CI]: 80%, 93%) and 72% (95% CI: 62%, 83%), recurrence-free survival was 85% (95% CI: 79%, 91%) and 69% (95% CI: 59%, 79%) (improved over surgery), and disease-specific survival was 94% (95% CI: 90%, 98%) at both 5 years and 10 years (similar to surgery), respectively. The 10-year risk of hemodialysis was 2.3%. Risk of metachronous RCC was 6%. Charlson/Deyo Combined Comorbidity score analysis showed decreasing overall survival with increasing comorbidity index. The PCA cohort outperformed both RN- and PN-matched subgroups in all Charlson/Deyo Combined Comorbidity score categories. Conclusion Percutaneous cryoablation yielded a 10-year disease-specific survival of 94%, equivalent to that reported after radical or partial nephrectomy. Overall survival probability after percutaneous cryoablation at 5 years and 10 years was longer than for radical or partial nephrectomy, especially for patients at higher risk (Charlson/Deyo Combined Comorbidity score ≥2). © RSNA, 2020.

Adrenal vein sampling with and without cosyntropin stimulation for detection of surgically remediable aldosteronism.

CONTEXT AND OBJECTIVE: Bilateral adrenal vein sampling (AVS), the diagnostic standard for identifying surgically remediable aldosteronism (SRA), is commonly performed after cosyntropin stimulation (post-ACTHstim). The role of AVS without cosyntropin stimulation (pre-ACTHstim) has not been established. The selectivity index (SI), the adrenal vein (av) serum cortisol concentration divided by that in a peripheral vein, confirms av sampling. The minimally acceptable SI is controversial. The objectives of this study were to determine the role of pre-ACTHstim AVS and a predetermined SI. DESIGN: Using biochemical cure as the endpoint, we performed a retrospective head-to-head comparison of pre-ACTHstim AVS to post-ACTHstim AVS. The specificity of a predetermined minimum SI of 1.5 in pre-ACTHstim AVS was determined. PATIENTS: At a regional AVS referral centre, we analysed 32 patients who had undergone simultaneous bilateral AVS both pre- and post-ACTHstim and had returned for postadrenalectomy evaluation. MEASUREMENTS: Simultaneous bilateral AVS was performed with measurements of venous concentrations of aldosterone and cortisol. End points were postadrenalectomy plasma renin activity, serum aldosterone concentration, and number of antihypertensive medications. RESULTS: All 32 patients achieved a biochemical cure following adrenalectomy. The two AVS protocols were complementary. Notably, seven patients (22%; CI = 11-38) were found to have SRA by a lateralization index (LI) > 4 on the pre-ACTHstim AVS, but not on the post-ACTHstim AVS. SI pre-ACTHstim was divided into tertiles. Specificity was 100% in all. CONCLUSIONS: Simultaneous bilateral AVS performed both pre-ACTHstim and post-ACTHstim maximizes SRA identification. A SI of 1.5 pre-ACTHstim does not reduce specificity.

Single 15-Min Protocol Yields the Same Cryoablation Size and Margin as the Conventional 10-8-10-Min Protocol: Results of Kidney and Liver Swine Experiment.

INTRODUCTION: The objective was to determine the ablation size of a single 15-min freeze and compare it with the conventional 10-min freeze-8-min thaw-10-min freeze protocol. Secondary objectives were to determine the ablation margin and to ascertain whether islands of viable tissue remain within the ablation zone. MATERIALS AND METHODS: Five adult swine under general anesthesia were used. After surgical abdominal exposure, two ablations were performed in liver and two in kidney. One ablation utilized the 15-min and the second the 10-8-10-min protocol. At maximum ice-ball, tissue ink was infused via an angiographic catheter in hepatic or renal artery to stain the non-frozen tissue. Animals were euthanized and organs examined macro- and microscopically. RESULTS: Three histological regions were observed: (A) a viable/stained region representing the tissue outside the ice-ball, (B) a central necrotic area representing the ablated region within the ice-ball and (C) an unstained but viable margin representing the non-lethal margin within ice-ball. Ablation size did not vary with protocol but did for tissue type. Renal ablation was approximately 5 × 4 cm with both protocols, whereas liver ablation was approximately 6.7 × 4.4 cm. Ablation margin was measured at 1 mm irrespective of ablation protocol or tissue. No islands of viable tissue were identified within the ablation zone. DISCUSSION: Fifteen-minute cryoablation yielded an ablation size and margin identical to that of the conventional 10-8-10-min protocol. Within the ablated region, cell death was uniform. The only difference was a larger cryoablation zone in hepatic tissue compared to renal tissue, likely attributable to differences in blood perfusion.

CT-Guided, Percutaneous Ethanol Sympatholysis for Primary Hyperhidrosis.

PURPOSE: Primary hyperhidrosis (PH) typically involves the craniofacial (CF) or axillary-palmar (AP) region. Our purpose was to determine the safety and efficacy of CT-guided sympatholysis for treating PH. METHODS: In this prospective study, 39 consecutive patients with CF or AP PH were referred for percutaneous sympatholysis. Procedures were performed under CT guidance and minimal sedation. We treated level T2 for CF hyperhidrosis and T2, T3, and T4 for AP hyperhidrosis. Twenty-two-gauge spinal needles were placed bilaterally at the anterolateral surface of the vertebral body. After infiltration of lidocaine (2 mL), a neurological test was performed to exclude Horner syndrome. Neurolysis was effected with ethanol (2 mL) via each needle. Patients were discharged 1 h postoperatively and followed up at 1 week, 1 month, and then as clinically indicated. Disease-free Kaplan-Meier curves were compared using log-rank tests. Complications were categorized according to Common Terminology Criteria for Adverse Events. RESULTS: One patient failed the lidocaine test and was excluded. Of the 38 patients included in this cohort (16 men), mean age was 38 years (range 18-61), and mean follow-up was 18 months (range 1-36). Technical success for these 38 patients was 100%. Seventeen patients had symptom recurrence, 14 of whom were retreated. Efficacy was 72% for CF hyperhidrosis, 50% for AP hyperhidrosis, and 60% overall. There were three major complications (two pneumothoraces, one severe intercostal neuralgia requiring medication). CONCLUSIONS: CT-guided sympatholysis for CF or AP PH had 18-month efficacy rates of 72 and 50%, with a favorable risk profile. LEVEL OF EVIDENCE: Level 2b.

Resolution of generalized compensatory hyperhidrosis related to sympathectomy, after T2 sympatholysis.

Compensatory hyperhidrosis (CH) is common after sympathectomy, and most treatments are ineffective. We present a 36-year-old man whose CH was effectively treated with percutaneous sympatholysis. The patient's axillary-palmar hyperhidrosis had been treated with T3-4 sympathetic ligation. The patient developed CH involving the head, face, back, torso and feet and was referred for computed tomography-guided percutaneous T2 sympatholysis for craniofacial symptoms, after which the patient experienced resolution of CH (complete face/neck/feet and partial back/torso), despite the treated level being above the previous ligation.

Kidney Cancer.

The number of new cases of renal cell carcinoma has been steadily increasing since the 1960s, reaching 62,000 and 89,000 annually in the United States and Europe, respectively, in 2016. The current standard of care for early-stage disease is nephron-sparing surgery, which has a demonstrated long-term disease-free survival and an acceptable safety profile. Technical developments (thin, powerful probes and real-time image guidance systems) have allowed image-guided percutaneous ablation to become a viable option for stage I renal cell carcinoma. Because of the widespread use of cross-sectional imaging, most renal tumors (75%) are indeed detected incidentally at stage I (75%). As a result, ablation is a potentially curable intervention and one that could mitigate surgical risks. All 3 ablative modalities (radiofrequency ablation, microwave ablation, and cryoablation) have been extensively applied. The utilization of ablation was initially hampered by the lack of prospective, long-term oncologic data. As a result, ablation was reserved for specific subgroups of patients, for example, patients with solitary kidney, chronic kidney disease, or bilateral disease; poor surgical candidates; or patients with syndromes that predispose them to renal cell cancer. Recently, however, studies on percutaneous ablation for early-stage renal cancer have yielded prospective, long-term oncologic data, affirming the earlier, lower-level-evidence studies. The reported efficacy of ablation for stage I renal cancer (especially cryoablation) appears to rival that of the accepted standard of care (nephron-sparing surgery), whereas its safety profile is a decided advantage. In conclusion, image-guided percutaneous ablation should be considered a viable, curative option for stage IA renal cell carcinoma.

Hemorrhagic Complications of Percutaneous Cryoablation for Renal Tumors: Results from a 7-year Prospective Study.

PURPOSE: Cryoablation of renal tumors is assumed to have a higher risk of hemorrhagic complications compared to other ablative modalities. Our purpose was to establish the exact risk and to identify hemorrhagic risk factors. MATERIALS AND METHODS: This IRB approved, 7-year prospective study included 261 renal cryoablations. Procedures were under conscious sedation and CT guidance. Pre- and postablation CT was obtained, and hemorrhagic complications were CTCAE tabulated. Age, gender, tumor size, histology, and probes number were tested based on averages or proportions using their exact permutation distribution. "High-risk" subgroups (those exceeding the thresholds of all variables) were tested for each variable alone, and for all combinations of variable threshold values. We compared the subgroup with the best PPV using one variable, with the subgroup with the best PPV using all variables (McNemmar test). RESULTS: The hemorrhagic complication rate was 3.5 %. Four patients required transfusions, two required emergent angiograms, one required both a transfusion and angiogram, and two required bladder irrigation for outlet obstruction. Perirenal space hemorrhage was more clinically significant than elsewhere. Univariate risks were tumor size >2 cm, number of probes >2, and malignant histology (P = 0.005, 0.002, and 0.033, respectively). Multivariate analysis showed that patients >55 years with malignant tumors >2 cm requiring 2 or more probes yielded the highest PPV (7.5 %). CONCLUSIONS: Although older patients (>55 years old) with larger (>2 cm), malignant tumors have an increased risk of hemorrhagic complications, the low PPV does not support the routine use of embolization. Percutaneous cryoablation has a 3.5 % risk of significant hemorrhage, similar to that reported for other types of renal ablative modalities.

Amyloidosis: review and imaging findings.

Amyloidosis is a collection of pathophysiologically related disease entities caused by the extracellular deposition of abnormal fibrillar proteins called amyloid. The accumulation of amyloid may be systemic, involving many organs, or localized manifesting as infiltration of individual organs, or in the form of a focal, tumorlike lesion. Amyloidosis may develop in the setting of underlying conditions, usually chronic inflammatory diseases, in which case it is termed secondary, or it may involve no underlying disease and thus be primary or idiopathic. Amyloid infiltration leads to pathology through the disruption of normal tissue structure and function or through cytotoxic effects of intermediate forms of protein aggregates. Clinical manifestations of the disease vary and are nonspecific, increasing the need of imaging during the investigation of the disease. Imaging findings are diverse and not pathognomonic; however, combined with the patient's clinical history they can raise the suspicion of amyloidosis and direct toward its confirmation by biopsy. Radiologists should be familiar with the appearance of amyloidosis in various modalities to aid the early identification of the disease and direct toward prompt treatment planning. Such knowledge would provide the radiologist with an opportunity to contribute to patient care and aid reducing the high morbidity and mortality of the disease.

Extramedullary hemopoiesis.

Various chronic hematologic disorders that lead to ineffective hemopoiesis or inadequate bone marrow function (ie, chronic hemolytic anemias, thalassemia, sickle cell anemia, myelofibrosis of many causes, lymphoma, and leukemia) can potentially precipitate extramarrow new blood element creation. Extramarrow soft tissue that produces blood elements is called extramedullary hemopoietic tissue and the process extramedullary hemopoiesis (EMH). Sites commonly involved by EMH include the liver, spleen, lymph nodes, and most commonly, paravertebral regions, although other sites can sometimes be involved. Physicians rarely consider EMH in their differential diagnosis even in cases where it is warranted (diseases of ineffective erythropoiesis). This is likely because of the rarity of the condition and because imaging findings are nonspecific. We present here a systematic review of the imaging findings in EMH.

Efficacy and safety of percutaneous cryoablation for stage 1A/B renal cell carcinoma: results of a prospective, single-arm, 5-year study.

PURPOSE: Percutaneous cryoablation is gaining in popularity as a viable treatment option for renal cell carcinoma (RCC). We present the 5-year oncologic outcomes of a prospective trial. METHODS: Over a 5-year period, we treated 134 consecutive patients with biopsy-proven RCC with CT-guided percutaneous cryoablation. All were treated while under conscious sedation. Technical objective was for the ice ball to cover the lesion plus a 5-mm margin. Hydro- or air dissection was utilized to aid in technical success as needed. Efficacy was defined as the lack of enhancement and/or enlargement of a previously enhancing lesion on follow-up imaging. Safety was assessed by the common terminology criteria for adverse events (CTCAE), version 4.0. RESULTS: The 1-, 2-, 3-, 4-, and 5-year efficacy of percutaneous cryoablation for RCC was 99.2, 99.2, 98.9, 98.5, and 97.0%, respectively. Median tumor size was 2.8 ± 1.4 cm. All-cause mortality during the study period was 3 (none from RCC), yielding an overall 5-year survival of 97.8%. The cancer-specific 5-year survival was 100%. No patient developed metastatic disease during the follow-up period. The overall significant CTCAE version 4.0 complication rate was 6%, with the most frequent being transfusion-requiring hemorrhage, at 1.6%. There was one 30-day mortality unrelated to the procedure. CONCLUSION: CT-guided percutaneous cryoablation for renal cancer offers very high efficacy, approaching that of the gold standard, with a more favorable safety profile.

Single-center comparative oncologic outcomes of surgical and percutaneous cryoablation for treatment of renal tumors.

PURPOSE: To compare outcomes between patients undergoing surgical and percutaneous cryoablation for treatment of renal masses and identify prognostic variables that determine survival. PATIENTS AND METHODS: We retrospectively evaluated the medical records of 194 patients who underwent cryoablation for renal tumors between 1997 and 2008 at a single large center. Patient demographics, tumor characteristics, perioperative data, and follow-up details were recorded. Univariate and multivariate Cox proportional hazards analysis was performed to identify predictors of overall (OS), cancer-specific (CSS), and recurrence-free survival (RFS). RESULTS: Cryoablation was performed percutaneously (PCA) in 141 patients for 154 tumors, while 53 patients were treated surgically (SCA) using an open or laparoscopic approach for 54 tumors. Mean follow-up was 44.5 months in SCA and 36.1 months in PCA. PCA had a shorter duration of hospital stay (0.7 days vs 3.2 days, P<0.0001). The rate of residual (P=0.38) and recurrent disease (P=0.18) was not significantly different between the two groups. Five-year OS, CSS, and RFS were 78.81%, 100%, and 85.23% for SCA, and 77.71%, 98%, and 95.56% for PCA, respectively; the type of approach was not predictive of OS, CSS, and RFS. CONCLUSIONS: SCA and PCA both provide adequate oncologic control for renal masses. Duration of hospital stay was lower in patients undergoing PCA.

Renal function and oncologic outcomes after cryoablation or partial nephrectomy for tumors in solitary kidneys.

PURPOSE: Preservation of renal function is of paramount importance in patients with tumors in solitary kidneys. We compared the renal function and oncologic outcomes of patients treated by partial nephrectomy with those of patients treated by cryoablation for solitary kidney tumors. MATERIALS AND METHODS: All patients with solitary kidneys who were treated for renal tumors at our institution between 1997 and 2007 were included in the screen. We retrospectively identified 23 patients who underwent cryoablation and 15 patients who underwent partial nephrectomy. RESULTS: The two groups were similar with regard to age, gender, and tumor laterality. Patients in the partial nephrectomy group had a larger tumor size (3.4 cm vs. 2.5 cm, p=0.01), higher mean estimated blood loss (316 cc vs. 87 cc, p<0.001), longer duration of hospital stay (5.8 vs. 1.8 days, p<0.001), and a higher rate of perioperative complications (53.3% vs. 8.7% patients, p=0.03). Percentage changes in the glomerular filtration rate postoperatively and on follow-up were found to be similar in the two groups. Both the cryoablation and the partial nephrectomy groups with mean follow-ups of 31.2 months and 30.8 months, respectively, had evidence of local or distant recurrence in 3 patients each (13% and 20% respectively, p=0.7). Both groups had a similar mean overall survival (88.9 and 86.9 months in the cryoablation and partial nephrectomy groups, respectively, p=0.8). CONCLUSIONS: For tumors in solitary kidneys, renal functional and clinical outcomes for cryoablation were not significantly different from those for partial nephrectomy. However, cryoablation has the distinct advantage of a lower morbidity rate and can be preferentially offered to selected cases.

Chemoembolization decreases drop-off risk of hepatocellular carcinoma patients on the liver transplant list.

INTRODUCTION: The drop-off risk for patients awaiting liver transplantation for hepatocellular carcinoma (HCC) is 22%. Transplant liver availability is expected to worsen, resulting in longer waiting times and increased drop-off rates. Our aim was to determine whether chemoembolization can decrease this risk. PATIENTS AND METHODS: Eighty-seven consecutive HCC patients listed for liver transplant (Milan criteria) underwent statistical comparability adjustments using the propensity score (Wilcoxon, Fisher's, and chi-square tests). Forty-three nonchemoembolization patients and 22 chemoembolization patients were comparable for Child-Pugh and Model for End-Stage Liver Disease scores, tumor size and number, alpha fetoprotein (AFP) levels, and cause of cirrhosis. We calculated the risk of dropping off the transplant list by assigning a transplant time to those who dropped off (equal probability with patients who were on the list longer than the patient in question). The significance level was obtained by calculating the simulation distribution of the difference compared with the permutations of chemoembolization versus nonchemoembolization assignment of the patients. Kaplan-Meier estimators (log-rank test) were used to determine survival rates. RESULTS: Median follow-up was 187 ± 110 weeks (range 38 to 435, date of diagnosis). The chemoembolization group had an 80% drop-off risk decrease (15% nonchemoembolization versus 3% chemoembolization, p = 0.04). Although survival was better for the chemoembolization group, it did not reach statistical significance. Two-year survival for the nonchemoembolization and chemoembolization group was 57.3% ± 7.1% and 76.0% ± 7.9%, respectively (p = 0.078). CONCLUSIONS: Chemoembolization appears to result in a significant decrease in the risk of dropping off liver transplant list for patients with HCC and results in a tendency toward longer survival.

Complications of renal cryoablation: a single center experience.

PURPOSE: We describe perioperative complications associated with renal cryoablation and identify potential risk factors for certain complications. MATERIALS AND METHODS: We retrospectively analyzed the medical records of patients with unifocal renal masses treated with cryosurgery at a single center between 1997 and 2007. All complications associated with these procedures were documented and classified into grades 1 to 5 by the Clavien surgical complication classification. In-depth analysis was done to identify potential risk factors for the most common complications. RESULTS: We evaluated 101 percutaneous, 52 laparoscopic and 9 open procedures. Complications were noted in 38 procedures (23.5%), including grades 1 to 4 in 19 (11.7%), 8 (4.9%), 5 (3.1%) and 6 (3.7%), respectively, as the severest complication. The most common complication was flank pain (11 procedures), followed by perinephric hematoma and cardiovascular complications (10 each). Mass size (p = 0.001), number of cryoablation probes (p <0.001) and chronic anticoagulation (p <0.05) were associated with an increased incidence of significant hematoma. Cardiovascular complications were more common when upper pole lesions were treated, and when an open approach was used (each p <0.05). Respiratory complications occurred in 7 procedures and were associated with patient age (p <0.05) and mass size (p <0.01). CONCLUSIONS: Cryoablation is a relatively safe procedure with a low complications rate in properly selected patients. We identified potential risk factors that may help identify patients most at risk for certain complications and consequently assist in preprocedural planning and counseling.