Technical Feasibility and Safety of Image-Guided Biphasic Monopolar Pulsed Electric Field Ablation of Metastatic and Primary Malignancies.

PURPOSE: To assess the technical feasibility and safety of image-guided percutaneous biphasic monopolar pulsed electric field (PEF) ablation of primary and metastatic tumors. METHODS AND METHODS: With IRB approval and HIPAA compliance, this retrospective, single-institution study cohort of 17 patients (mean age: 53.5 years, range: 20 - 94 years) with overall progressive disease underwent 26 PEF ablation procedures for 30 metastatic (90%) and primary (10%) target lesions in the thorax (n=20), abdomen (n=7), and head and neck (n=3). Concurrent systemic therapy was used in 14/17 patients (82%). Follow-up imaging was scheduled for 1, 3, and 6 months after PEF ablation, and target and off-target lesion sizes were recorded. The overall response was assessed by the RECIST 1.1 criteria with imaging immediately before PEF serving as baseline. Adverse events (AEs) were determined by the Society of Interventional Radiology classification. RESULTS: PEF ablation procedures were well tolerated and technically feasible for all 17 of 17 patients. The mean initial size of the target and off-target tumors were 2.6±1.5 cm (range: 0.4 - 6.9cm) and 2.2±1.1 cm (range: 1.0 - 5.2cm), respectively. Overall, 15/30 (50%) target lesions and 12/24 (50%) off-target lesions were unchanged or decreased in size at the patient's last follow-up. Eight patients had overall stable disease (47%) at the last follow-up. There were nine mild (9/26, 35%) and one moderate (1/26, 4%) AE. CONCLUSION: All PEF procedures were technically feasible with one moderate AE and stable disease for 47% of patients with a median follow-up period of three months.

Comparison of LIRADS 5 Image Guided Core Biopsy Derived From Formalin Fixed and Frozen Tissue Cores for Radiogenomics and Radioproteomics Analysis in Well, Moderate and Poorly Differentiated Hepatocellular Carcinoma.

The aim of this pilot study is to evaluate and compare the quality of the genomics and proteomics data obtained from paired Formalin Fixed Paraffin Embedded (FFPE) and frozen (FF) tissue percutaneous core biopsies of Liver Imaging Reporting and Data System 5 (LIRADS 5) hepatocellular carcinoma (HCC) of varying histological grades. The preliminary data identified differentially expressed proteins and genes in poor, moderate and well differentiated HCC biopsies, with a greater efficacy in fresh frozen samples. The data offered valuable insights into the characteristics and suitability of samples for future studies.

Characterization of Microwave Generator Energy and Ablation Volumes following Transarterial Embolization in an In Vivo Porcine Liver Model.

PURPOSE: To characterize the relationship between ablation zone volume (AZV) and microwave ablation (MWA) energy in an in vivo porcine liver model following arterial embolization. MATERIALS AND METHODS: With Institutional Animal Care and Use Committee (IACUC) approval, 11 female swine underwent either right (n = 5) or left (n = 6) hepatic artery embolization under fluoroscopic guidance. Subsequently, ultrasound (US)-guided MWA was performed in each liver segment (left lateral, left medial, right medial, and right lateral) at either 30 W (n = 4 lobes), 60 W (n = 4), 65 W (n = 20), 90 W (n = 8), 120 W (n = 4), or 140 W (n = 4) continuously for 5 minutes. Postprocedural volumetric segmentation was performed on standardized multiphase T1 magnetic resonance (MR) imaging sequences. RESULTS: Mean AZVs in embolized lobes (15.8 mL ± SD 10.6) were significantly larger than those in nonembolized lobes (11.2 mL ± SD 6.5, P < .01). MWA energy demonstrated significant positive linear correlation with both embolized (R2 = 0.66, P < .01) and nonembolized (R2 = 0.64, P < .01) lobes. The slope of the linear models corresponded to a 0.95 mL/kJ (SD ± 0.16) and 0.54 mL/kJ (SD ± 0.09) increase in ablation volume per applied kilojoule of energy (E) in embolized and nonembolized lobes, respectively. In the multivariate model, embolization status significantly modified the relationship between E and AZV as described by the following interaction term: 0.42∗E∗(embolization status) (P = .031). CONCLUSIONS: Linear models demonstrated a near 1.8-fold increase in ratio of AZV per unit E, R(AZV:E), when applied to embolized lobes relative to nonembolized lobes. Absolute AZV differences between embolized and nonembolized lobes were greater at higher-power MWA.

Deep learning-based automatic pipeline for 3D needle localization on intra-procedural 3D MRI.

PURPOSE: Accurate and rapid needle localization on 3D magnetic resonance imaging (MRI) is critical for MRI-guided percutaneous interventions. The current workflow requires manual needle localization on 3D MRI, which is time-consuming and cumbersome. Automatic methods using 2D deep learning networks for needle segmentation require manual image plane localization, while 3D networks are challenged by the need for sufficient training datasets. This work aimed to develop an automatic deep learning-based pipeline for accurate and rapid 3D needle localization on in vivo intra-procedural 3D MRI using a limited training dataset. METHODS: The proposed automatic pipeline adopted Shifted Window (Swin) Transformers and employed a coarse-to-fine segmentation strategy: (1) initial 3D needle feature segmentation with 3D Swin UNEt TRansfomer (UNETR); (2) generation of a 2D reformatted image containing the needle feature; (3) fine 2D needle feature segmentation with 2D Swin Transformer and calculation of 3D needle tip position and axis orientation. Pre-training and data augmentation were performed to improve network training. The pipeline was evaluated via cross-validation with 49 in vivo intra-procedural 3D MR images from preclinical pig experiments. The needle tip and axis localization errors were compared with human intra-reader variation using the Wilcoxon signed rank test, with p < 0.05 considered significant. RESULTS: The average end-to-end computational time for the pipeline was 6 s per 3D volume. The median Dice scores of the 3D Swin UNETR and 2D Swin Transformer in the pipeline were 0.80 and 0.93, respectively. The median 3D needle tip and axis localization errors were 1.48 mm (1.09 pixels) and 0.98°, respectively. Needle tip localization errors were significantly smaller than human intra-reader variation (median 1.70 mm; p < 0.01). CONCLUSION: The proposed automatic pipeline achieved rapid pixel-level 3D needle localization on intra-procedural 3D MRI without requiring a large 3D training dataset and has the potential to assist MRI-guided percutaneous interventions.

Combination transarterial chemoembolization and microwave ablation vs. microwave ablation monotherapy for hepatocellular carcinomas greater than 3 cm: a comparative study.

PURPOSE: To evaluate the efficacy of combination therapy using transarterial chemoembolization with microwave ablation (MWA) therapy vs. MWA monotherapy for hepatocellular carcinomas (HCCs) >3 cm in size. METHODS: This two-arm retrospective observational study included patients with HCCs >3 cm who underwent either combination therapy (29 patients) or MWA monotherapy (35 patients) between 2014 and 2020. The treatment outcomes related to primary treatment efficacy, local tumor progression (LTP), tumor control rate, and overall survival were compared between each cohort. RESULTS: The technical success and primary efficacy were 96.56% and 100.00% in the combination therapy cohort, and 91.42% and 100.00% in the MWA cohort, respectively, over a mean follow-up period of 27.6 months. The 1- and 3-year rates of LTP-free survival were 78.57% and 69.56% in the combination therapy cohort, vs. 72.45% and 35.44% in the MWA cohort, respectively (P = 0.001). The overall progression-free survival was longer in the combination therapy cohort compared with the MWA cohort (median: 56.0 vs. 13.0 months; P = 0.017). With the incorporation of additional locoregional therapy, the overall survival rates were not significantly different, with 1- and 3-year overall survival rates of 100.00% and 88.71% in the combination therapy cohort and rates of 90.15% and 82.76% in the MWA cohort, respectively (P = 0.235). CONCLUSION: The combination therapy provided significantly longer upfront LTP-free survival in HCCs >3 cm when compared with the MWA treatment alone, albeit with similar local tumor control and overall survival rates when accounting for additional locoregional therapies.

Comprehensive tissue deconvolution of cell-free DNA by deep learning for disease diagnosis and monitoring.

Plasma cell-free DNA (cfDNA) is a noninvasive biomarker for cell death of all organs. Deciphering the tissue origin of cfDNA can reveal abnormal cell death because of diseases, which has great clinical potential in disease detection and monitoring. Despite the great promise, the sensitive and accurate quantification of tissue-derived cfDNA remains challenging to existing methods due to the limited characterization of tissue methylation and the reliance on unsupervised methods. To fully exploit the clinical potential of tissue-derived cfDNA, here we present one of the largest comprehensive and high-resolution methylation atlas based on 521 noncancer tissue samples spanning 29 major types of human tissues. We systematically identified fragment-level tissue-specific methylation patterns and extensively validated them in orthogonal datasets. Based on the rich tissue methylation atlas, we develop the first supervised tissue deconvolution approach, a deep-learning-powered model, cfSort, for sensitive and accurate tissue deconvolution in cfDNA. On the benchmarking data, cfSort showed superior sensitivity and accuracy compared to the existing methods. We further demonstrated the clinical utilities of cfSort with two potential applications: aiding disease diagnosis and monitoring treatment side effects. The tissue-derived cfDNA fraction estimated from cfSort reflected the clinical outcomes of the patients. In summary, the tissue methylation atlas and cfSort enhanced the performance of tissue deconvolution in cfDNA, thus facilitating cfDNA-based disease detection and longitudinal treatment monitoring.

Hepatocellular Adenomas: Molecular Basis and Multimodality Imaging Update.

Hepatocellular adenomas (HCAs) are a family of liver tumors that are associated with variable prognoses. Since the initial description of these tumors, the classification of HCAs has expanded and now includes eight distinct genotypic subtypes based on molecular analysis findings. These genotypic subtypes have unique derangements in their cellular biologic makeup that determine their clinical course and may allow noninvasive identification of certain subtypes. Multiphasic MRI performed with hepatobiliary contrast agents remains the best method to noninvasively detect, characterize, and monitor HCAs. HCAs are generally hypointense during the hepatobiliary phase; the ß-catenin-mutated exon 3 subtype and up to a third of inflammatory HCAs are the exception to this characterization. It is important to understand the appearances of HCAs beyond their depictions at MRI, as these tumors are typically identified with other imaging modalities first. The two most feared related complications are bleeding and malignant transformation to hepatocellular carcinoma, although the risk of these complications depends on tumor size, subtype, and clinical factors. Elective surgical resection is recommended for HCAs that are persistently larger than 5 cm, adenomas of any size in men, and all ß-catenin-mutated exon 3 HCAs. Thermal ablation and transarterial embolization are potential alternatives to surgical resection. In the acute setting of a ruptured HCA, patients typically undergo transarterial embolization with or without delayed surgical resection. This update on HCAs includes a review of radiologic-pathologic correlations by subtype and imaging modality, related complications, and management recommendations. © RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Contrast-enhanced ultrasound for abdominal image-guided procedures.

INTRODUCTION: Since FDA approval for contrast-enhanced ultrasound (CEUS), clinical applications have increased to include diagnostic imaging of hepatic, renal, and other abdominal lesions. The modality has also demonstrated utility in certain image-guided procedures. Intravascular ultrasound contrast agents use microbubbles to improve visibility of solid tumors. Lesions not well seen on grayscale or Doppler ultrasound may become amenable to CEUS-guided biopsy or ablation. MATERIALS AND METHODS: This pictorial essay provides eleven examples to illustrate the current use of CEUS in a variety of abdominal image-guided procedures. Hepatic, renal, peritoneal, and soft tissue cases are presented. CONCLUSION: CEUS can improve visualization and targeting in abdominal image-guided procedures, without nephrotoxicity or radiation exposure.

MR imaging biomarkers in HCC: outcomes correlation in liver transplant listed patients.

PURPOSE: To determine hepatocellular carcinoma (HCC) magnetic resonance imaging (MRI) biomarkers that enable the prediction of delisting from tumor progression versus successful transplantation in patients listed for orthotopic liver transplantation (OLT). METHODS: With IRB approval and HIPPA compliance, patients with HCC awaiting OLT who were delisted due to HCC progression from 2006 to 2015 were identified. Patients with adequate MR images for review were subsequently matched with a cohort of patients successfully bridged to OLT in the same time period. Matching considered the tumor stage and the dominant treatment strategy adopted to bridge the patient to OLT. Potential MRI features were evaluated by univariable and multivariable analysis using a conditional logistic model. RESULTS: There were 53 patients included in each cohort. On uni-variable analysis, significant unfavorable MR imaging features included T2 hyperintensity (odds ratio [OR], 19.0), infiltrative border (OR, 7.50), lobulated shape (OR, 4.5), T1 hypointensity (OR, 3.0), heterogeneous arterial enhancement (OR, 7.0), and corona venous enhancement (OR, 4.0). A significant favorable MR imaging feature was the presence of intralesional fat (OR = .36). The best multivariable logistic prediction model derived from the above notable features included only T1 and T2 signal intensity, border definition, and absence of intra-lesional fat as significant variables, with an area under the receiver operating characteristic curve (AUC) of .86 in the prediction of delisting. CONCLUSION: Select MR imaging features of HCC at presentation before any treatment are significantly associated with the risk of tumor progression regardless of tumor stage and treatment strategy in patients awaiting liver transplantation.

Hepatocellular Adenoma Subtypes Based on 2017 Classification System: Exploratory Study of Gadoxetate Disodium-Enhanced MRI Features With Proposal of a Diagnostic Algorithm.

BACKGROUND. The classification of hepatocellular adenomas (HCAs) was updated in 2017 on the basis of genetic and molecular analysis. OBJECTIVE. The purpose of this article was to evaluate features on gadoxetate disodium-enhanced MRI of HCA subtypes on the basis of the 2017 classification and to propose a diagnostic algorithm for determining subtype using these features. METHODS. This retrospective study included 56 patients (49 women, seven men; mean age, 37 ± 13 [SD] years) with histologically confirmed HCA evaluated by gadoxetate disodium-enhanced MRI from January 2010 to January 2021. Subtypes were reclassified using 2017 criteria: hepatocyte nuclear factor-1α mutated HCA (HHCA), inflammatory HCA (IHCA), ß-catenin exon 3 activated HCA (ß-HCA), mixed inflammatory and ß-HCA (ß-IHCA), sonic hedgehog HCA (shHCA), and unclassified HCA (UHCA). Qualitative MRI features were assessed. Liver-to-lesion contrast enhancement ratios (LLCERs) were measured. Subtypes were compared, and a diagnostic algorithm was proposed. RESULTS. The analysis included 65 HCAs: 16 HHCAs, 31 IHCAs, six ß-HCA, four ß-IHCA, five shHCA, and three UHCAs. HHCAs showed homogeneous diffuse intralesional steatosis in 94%, whereas all other HCAs showed this finding in 0% (p < .001). IHCAs showed the "atoll" sign in 58%, whereas all other HCAs showed this finding in 12% (p < .001). IHCAs showed moderate T2 hyperintensity in 52%, whereas all other HCAs showed this finding in 12% (p < .001). The ß-HCAs and ß-IHCAs occurred in men in 63%, whereas all other HCAs occurred in men in 4% (p < .001). The ß-HCAs and ß-IHCAs had a mean size of 10.1 ± 6.8 cm, whereas all other HCAs had a mean size of 5.1 ± 2.9 cm (p = .03). The ß-HCAs and ß-IHCAs showed fluid components in 60%, whereas all other HCAs showed this finding in 5% (p < .001). Hepatobiliary phase iso- or hyperintensity was observed in 80% of ß-HCAs and ß-IHCAs versus 5% of all other HCAs (p < .001). Hepatobiliary phase LLCER was positive in nine HCAs (eight ß-HCAs and ß-IHCAs; one IHCA). The shHCA and UHCA did not show distinguishing features. The proposed diagnostic algorithm had accuracy of 98% for HHCAs, 83% for IHCAs, and 95% for ß-HCAs or ß-IHCAs. CONCLUSION. Findings on gadoxetate disodium-enhanced MRI, including hepatobiliary phase characteristics, were associated with HCA subtypes using the 2017 classification. CLINICAL IMPACT. The algorithm identified common HCA subtypes with high accuracy, including those with ß-catenin exon 3 mutations.

CT-monitored minimal ablative margin control in single-session microwave ablation of liver tumors: an effective strategy for local tumor control.

OBJECTIVES: To investigate the usefulness of minimal ablative margin (MAM) control by intra-procedural contrast-enhanced CT (CECT) in microwave ablation (MWA) of liver tumors. METHODS: A total of 334 consecutive liver tumors (240 hepatocellular carcinomas [HCCs] and 94 colorectal liver metastases [CRLMs]) in 172 patients treated with percutaneous MWA were retrospectively included. MAM of each tumor was assessed after expected ablation completion using intra-procedural CECT, allowing within-session additional ablation to any potentially insufficient margin. On immediate post-MWA MRI, complete ablation coverage of tumor and final MAM status were determined. The cumulative local tumor progression (LTP) rate was estimated by using the Kaplan-Meier method. To identify predictors of LTP, Cox regression analysis with a shared frailty model was performed. RESULTS: Intra-procedural CECT findings prompted additional ablation in 18.9% (63/334) of tumors. Final complete ablation coverage of tumor and sufficient MAM were determined by MRI to be achieved in 99.4% (332/334) and 77.5% (259/334), and their estimated 6-month, 1-year, and 2-year LTP rates were 3.2%, 7.5%, and 12.9%; and 1.0%, 2.1%, and 6.9%, respectively. Insufficient MAM on post-MWA MRI, perivascular tumor location, and tumor size (cm) were independent risk factors for LTP (hazard ratio = 14.4, 6.0, and 1.1, p < 0.001, p = 0.003, and p = 0.011, respectively), while subcapsular location and histology (HCC vs CRLM) were not. CONCLUSIONS: In MWA of liver tumors, intra-procedural CECT monitoring of minimal ablative margin facilitates identification of potentially suboptimal margins and guides immediate additional intra-session ablation to maximize rates of margin-sufficient ablations, the latter being a highly predictive marker for excellent long-term local tumor control. KEY POINTS: • In MWA of liver tumors, intra-procedural CECT can identify potentially suboptimal minimal ablative margin, leading to immediate additional ablation in a single treatment session. • Achieving a finally sufficient ablative margin through the MWA with intra-procedural CECT monitoring of minimal ablative margin results in excellent local tumor control.

Safety of percutaneous, image-guided biopsy of hepatocellular carcinoma with and without concurrent ablation.

PURPOSE: To determine the prevalence of adverse events after image-guided biopsy of histologically proven hepatocellular carcinomas (HCC) using a standardized, indirect access, coaxial biopsy technique. METHODS: In this IRB-approved, HIPAA compliant, and retrospective study, we evaluated all consecutive adult patients from 2011 to 2016 who underwent image-guided biopsy of HCC with and without concurrent ablation. Tumor seeding was defined as any new lesion along the needle tract on subsequent imaging. Adverse events were graded using both the Clavien-Dindo Complication Classification system and the most recently proposed Society of Interventional Radiology (SIR) Adverse Event Classification System. RESULTS: A total of 383 patients underwent 398 biopsies (64 ± 11 years; 112 women, 271 men). Most patients (282; 71%) underwent concurrent ablation. Adverse events occurred after 18 biopsies (4.5%): 13 were Grade I (Clavien-Dindo) or minor (SIR) and included hematoma (7), hepatic vein thrombus (2), portal vein thrombus (2), moderate pleural effusion (1), and small pneumothorax (1). The remaining 5 (1.3%) adverse events were classified as Grade II-IIIa (Clavien-Dindo) or moderate (SIR) and included hematoma requiring blood products (n = 1), arrhythmia (n = 1), and symptomatic pleural effusions requiring treatment (n = 3). Baseline age, sex, cause of liver disease, HCC diameter, and HCC grade were not associated with adverse events. There were no tumor seeding events after a median follow-up of 611 days (interquartile range of 211-1104). CONCLUSION: Percutaneous image-guided tissue sampling using a standardized, indirect access, coaxial technique can be performed safely with and without concurrent ablation by trained cross-sectional interventional radiologists at a tertiary liver transplant center.

Free-breathing 3D stack-of-radial MRI quantification of liver fat and R2* in adults with fatty liver disease.

PURPOSE: To investigate the agreement, intra-session repeatability, and inter-reader agreement of liver proton-density fat fraction (PDFF) and R2* quantification using free-breathing 3D stack-of-radial MRI, with and without self-gated motion compensation, compared to reference breath-hold techniques in subjects with fatty liver disease (FLD). METHODS: In this institutional review board-approved prospective study, thirty-eight adults with FLD and/or iron overload (24 male, 58 ± 12 years) were imaged at 3T using free-breathing stack-of-radial MRI, breath-hold 3D Cartesian MRI, and breath-hold single-voxel MR spectroscopy (SVS). Each sequence was acquired twice in random order. To assess agreement compared to reference breath-hold techniques, the dependency of liver PDFF and/or R2* quantification on the sequence, radial sampling factor, and radial self-gating temporal resolution was assessed by calculating the Bayesian mean difference (MDB) of the posteriors. Intra-session repeatability and inter-reader agreement (two independent readers) were assessed by the coefficient of repeatability (CR) and intraclass correlation coefficient (ICC), respectively. RESULTS: Thirty-five participants (21 male, 57 ± 12 years) were included for analysis. Both free-breathing radial MRI techniques (with and without self-gating) achieved ICC ≥ 0.92 for quantifying PDFF and R2*, and quantified PDFF with MDB < 1.2% compared to breath-hold techniques. Free-breathing radial MRI required self-gating to accurately quantify R2* (MDB < 10s-1 with self-gating; MDB < 50s-1 without self-gating). The radial sampling factor affected PDFF and R2* quantification while the radial self-gating temporal resolution only affected R2* quantification. Repeated self-gated free-breathing radial MRI scans achieved CR < 3% and CR < 27 s-1 for PDFF and R2*, respectively. CONCLUSION: A free-breathing stack-of-radial MRI technique with self-gating demonstrated agreement, repeatability, and inter-reader agreement compared to reference breath-hold techniques for quantification of liver PDFF and R2* in adults with FLD.

Steady-state ferumoxytol-enhanced MRI: early observations in benign abdominal organ masses and clinical implications.

INTRODUCTION: The off-label use of ferumoxytol as a vascular MR imaging agent is growing rapidly. However, the properties of ferumoxytol suggest that it may play an important role in the detection and characterization of abdominal mass lesions. METHODS: Thirty-six patients with benign abdominal mass lesions who underwent MR angiography with ferumoxytol also had T2-weighted HASTE imaging and fat-suppressed 3D T1-weighted imaging. The T1 and T2 enhancement characteristics of the lesions were analyzed and correlated with other imaging modalities and/or surgical findings and/or clinical follow-up. RESULTS: In all patients with benign masses in the liver (n = 22 patients), spleen (n = 6 patients), kidneys (n = 33 patients), adrenal (n = 2 patients) and pancreas (n = 4 patients), based on the enhancement characteristics with ferumoxytol, readers were confident of the benign nature of the lesions and their conclusions were consistent with correlative imaging, tissue sampling and follow-up. One patient with a suspicious enhancing 2F Bosniak renal cyst had renal cell carcinoma confirmed on biopsy. CONCLUSION: Ferumoxytol-enhanced MRI can increase diagnostic confidence for benign abdominal masses and can increase the conspicuity of mass lesions, relative to unenhanced MRI.

Nonalcoholic fatty liver disease-related hepatocellular carcinoma growth rates and their clinical outcomes.

AIM: Nonalcoholic fatty liver disease (NAFLD)-associated hepatocellular carcinoma (HCC) is projected to become the leading indication for liver transplantation. Previous studies indicate that tumor growth rates (TGR) may predict survival and were helpful in determining HCC surveillance intervals. Therefore, we aimed to determine its usefulness in predicting clinical outcomes and treatments. METHODS: We conducted a retrospective study of hepatitis B, C and NAFLD-HCC cases. TGR was measured using 2-consecutive pre-treatment contrast-enhanced imaging studies ≥ 25 days apart. A multivariate regression model was used to determine predictors of TGR. In addition, the Cox regression model was used to evaluate the relationship between TGR and overall survival. RESULTS: From 2000-2019, the study cohort comprised 38, 60, and 47 HBV, HCV, and NAFLD patients, respectively, with TGRs. NAFLD-HCC tumor size was inversely correlated to the extent of liver disease as measured by Child-Pugh score (7.2 cm in non-cirrhosis; 3.7 cm, 2.6 cm, and 2.1 cm in Child A, B, and C, respectively; P < 0.001). After adjusting for baseline characteristics, the TGR per month was fastest in HBV (9.4%, 95%CI: 6.3%-12.5%) compared to HCV (4.9%, 95%CI: 2.8%-7%) and NAFLD patients (3.6%, 95%CI: 1.6%-6.7%). Predictors of TGR included elevated AFP, low albumin, and smaller tumor size. Fast TGR in viral etiologies had higher mortality [adj. hazard ratio (HR) = 2.6, 95%CI: 1.2-5.7, P = 0.02] than slow TGRs, independent of treatments. Fast TGR in NAFLD had a trend towards higher mortality (HR = 3.6, 95%CI: 0.95-13.3, P = 0.059). CONCLUSION: NAFLD-HCC patients have more indolent growths than viral-related HCC TGRs. The addition of TGR as a biomarker may assist in stratifying treatment options.

Consensus Guidelines for the Definition of Time-to-Event End Points in Image-guided Tumor Ablation: Results of the SIO and DATECAN Initiative.

There is currently no consensus regarding preferred clinical outcome measures following image-guided tumor ablation or clear definitions of oncologic end points. This consensus document proposes standardized definitions for a broad range of oncologic outcome measures with recommendations on how to uniformly document, analyze, and report outcomes. The initiative was coordinated by the Society of Interventional Oncology in collaboration with the Definition for the Assessment of Time-to-Event End Points in Cancer Trials, or DATECAN, group. According to predefined criteria, based on experience with clinical trials, an international panel of 62 experts convened. Recommendations were developed using the validated three-step modified Delphi consensus method. Consensus was reached on when to assess outcomes per patient, per session, or per tumor; on starting and ending time and survival time definitions; and on time-to-event end points. Although no consensus was reached on the preferred classification system to report complications, quality of life, and health economics issues, the panel did agree on using the most recent version of a validated patient-reported outcome questionnaire. This article provides a framework of key opinion leader recommendations with the intent to facilitate a clear interpretation of results and standardize worldwide communication. Widespread adoption will improve reproducibility, allow for accurate comparisons, and avoid misinterpretations in the field of interventional oncology research. Published under a CC BY 4.0 license. Online supplemental material is available for this article. See also the editorial by Liddell in this issue.

Image-Guided Percutaneous Thermal Ablation of Oligometastatic Ovarian and Non-Ovarian Gynecologic Tumors.

PURPOSE: To assess the safety, feasibility, and efficacy of percutaneous thermal ablation (TA) in the treatment of metastatic gynecologic (GYN) tumors. MATERIALS AND METHODS: A study cohort of 42 consecutive women (mean age, 59. years; range, 25-78 years) with metastatic GYN tumors (119 metastatic tumors) treated with radiofrequency (n = 47 tumors), microwave (n = 47 tumors), or cryogenic (n = 30 tumors) ablation from over 2,800 ablations performed from January 2001 to January 2019 was identified. The primary GYN neoplasms consisted of ovarian (27 patients; 77 tumors; mean tumor diameter [MTD], 2.50 cm), uterine (7 patients; 26 tumors; MTD, 1.89 cm), endometrial (5 patients; 10 tumors; MTD, 2.8 cm), vaginal (2 patients; 5 tumors; MTD, 2.40 cm), and cervical (1 patient; 1 tumor; MTD, 1.90 cm) cancers. In order of descending frequency, metastatic tumors treated by TA were located in the liver or liver capsule (74%), lungs (13%), and peritoneal implants (9%). Single tumors were also treated in the kidneys, rectus muscle, perirectal soft tissue (2.5%), and retroperitoneal lymph nodes (1.6%). All efficacy parameters of TA and definitions of major and minor adverse events are categorized by the latest Society of Interventional Radiology reporting standards. RESULTS: The median follow-up of treated patients was 10 months. After the initial ablation, 95.6% of the patients achieved a complete tumor response confirmed by contrast-enhanced magnetic resonance imaging or computed tomography. On surveillance imaging, 8.5% of the ablated tumors developed local progression over a median follow-up period of 4.1 months. Five of 8 tumors with local recurrence underwent repeated treatment over a mean follow-up period of 18 months, and 4 of 5 tumors achieved complete eradication after 1 additional treatment session that resulted in a secondary efficacy of 80%. The overall technique efficacy of TA was 96.2% over a median follow-up period of 10 months. CONCLUSIONS: TA was safe and effective for the local control of metastatic GYN tumors in the lungs, abdomen, and pelvis, with an overall survival rate of 37.5 months and a local progression-free survival rate of 16.5 months, with only 4.8% of treated patients experiencing a major adverse event.

Automatic needle tracking using Mask R-CNN for MRI-guided percutaneous interventions.

PURPOSE: Accurate needle tracking provides essential information for MRI-guided percutaneous interventions. Passive needle tracking using MR images is challenged by variations of the needle-induced signal void feature in different situations. This work aimed to develop an automatic needle tracking algorithm for MRI-guided interventions based on the Mask Region Proposal-Based Convolutional Neural Network (R-CNN). METHODS: Mask R-CNN was adapted and trained to segment the needle feature using 250 intra-procedural images from 85 MRI-guided prostate biopsy cases and 180 real-time images from MRI-guided needle insertion in ex vivo tissue. The segmentation masks were passed into the needle feature localization algorithm to extract the needle feature tip location and axis orientation. The proposed algorithm was tested using 208 intra-procedural images from 40 MRI-guided prostate biopsy cases, and 3 real-time MRI datasets in ex vivo tissue. The algorithm results were compared with human-annotated references. RESULTS: In prostate datasets, the proposed algorithm achieved needle feature tip localization error with median Euclidean distance (dxy) of 0.71 mm and median difference in axis orientation angle (dθ) of 1.28°, respectively. In 3 real-time MRI datasets, the proposed algorithm achieved consistent dynamic needle feature tracking performance with processing time of 75 ms/image: (a) median dxy = 0.90 mm, median dθ = 1.53°; (b) median dxy = 1.31 mm, median dθ = 1.9°; (c) median dxy = 1.09 mm, median dθ = 0.91°. CONCLUSIONS: The proposed algorithm using Mask R-CNN can accurately track the needle feature tip and axis on MR images from in vivo intra-procedural prostate biopsy cases and ex vivo real-time MRI experiments with a range of different conditions. The algorithm achieved pixel-level tracking accuracy in real time and has potential to assist MRI-guided percutaneous interventions.