Is There a Role for Percutaneous Ablation for Early Stage Lung Cancer? What Is the Evidence?

PURPOSE OF REVIEW: For patients with early stage non-small-cell lung cancer (NSCLC), thermal ablation (TA) has become in the least two decades an option of treatment used worldwide for patients with comorbidities who are not surgical candidates. Here, we review data published with different TA techniques: radiofrequency ablation (RFA), microwave ablation (MWA) and cryoablation. This paper reviews also the comparison that has been made between TA and stereotactic radiotherapy (SBRT). RECENT FINDINGS: A majority of retrospective studies, the absence of comparative studies, and the variety of techniques make difficult to get evident data. Nevertheless, these stand-alone techniques have demonstrated local efficacy for tumors less than 3 cm and good tolerance on fragile patients. Many recent reviews and database analyses show that outcomes after TA (mainly RFA and MWA) are comparable to SBRT in terms of survival rates. For patients who are unfit for surgery, TA has demonstrated interesting results for safety, benefits in overall survival, and acceptable local control.

Homogeneous myxoid liposarcomas mimicking cysts on MRI: A challenging diagnosis.

OBJECTIVES: Myxoid liposarcoma (M-LPS) is the second most frequent subtype of liposarcoma. Foci of fat on MRI are strongly suggestive of this diagnosis. The aims of this study are to (i) assess the prevalence of perfectly homogeneous M-LPS-mimicking cyst and characterize their associated clinical and pathological features and to (ii) identify helpful clues to prevent misdiagnosis when encountered with a cyst-like lesion in soft tissue parts. METHODS: MR images from 32 consecutive pathologically proven M-LPS and round cell liposarcomas (RC-LPS) were retrospectively reviewed independently by two radiologists at our institution. Location, morphology, signals, lesion architecture, heterogeneity, margins and periphery were systematically assessed in each case. Medical records were checked for initial and definitive histopathological diagnosis, therapeutic managements and outcomes. Histopathological specimens of cyst-like M-LPS were reviewed for the study. RESULTS: We have identified seven perfectly homogeneous well-defined cyst mimickers (21.9%) located on the limbs, all but one being deep-seated. These tumors were significantly smaller than the conventional M-LPS (p = 0.0005). Six lesions were initially diagnosed as benign; 4 patients underwent marginal surgical resection without prior diagnosis and 2 cases were put under medical surveillance, one of which progressed towards classical RC-LPS on follow-up MRI. No specific pathological features could be identified nor were any clinical adverse outcomes recorded. CONCLUSION: "Cyst" on MRI, without pathological adjacent joint, necessitates ultrasonography with Doppler and intravenous Gadolinium agent injections as subsets of M-LPS can mimic cyst on MRI. Cyst-like M-LPS, due to their smaller size and relative favorable outcome, could have better prognosis.

Percutaneous thermal ablation of lung tumors - Radiofrequency, microwave and cryotherapy: Where are we going?

Main indications of percutaneous pulmonary thermal ablation are early stage non-small cell lung carcinoma (NSCLC) for patients who are not amenable to surgery and slow-evolving localized metastatic disease, either spontaneous or following a general treatment. Radiofrequency ablation (RFA) is the most evaluated technique. This technique offers a local control rate ranging between 80 and 90% for tumors <3cm in diameter. Other more recently used ablation techniques such as microwaves and cryotherapy could overcome some limitations of RFA. One common characteristic of these techniques is an excellent tolerance with very few complications. This article reviews the differences between these techniques when applied to lung tumors, indications, results and complications. Future potential associations with immunotherapy will be discussed.

Precision of manual two-dimensional segmentations of lung and liver metastases and its impact on tumour response assessment using RECIST 1.1.

BACKGROUND: Response evaluation criteria in solid tumours (RECIST) has significant limitations in terms of variability and reproducibility, which may not be independent. The aim of the study was to evaluate the precision of manual bi-dimensional segmentation of lung, liver metastases, and to quantify the uncertainty in tumour response assessment. METHODS: A total of 520 segmentations of metastases from six livers and seven lungs were independently performed by ten physicians and ten scientists on CT images, reflecting the variability encountered in clinical practice. Operators manually contoured the tumours, firstly independently according to the RECIST and secondly on a preselected slice. Diameters and areas were extracted from the segmentations. Mean standard deviations were used to build regression models and 95% confidence intervals (95% CI) were calculated for each tumour size and for limits of progressive disease (PD) and partial response (PR) derived from RECIST 1.1. RESULTS: Thirteen aberrant segmentations (2.5%) were observed without significant differences between the physicians and scientists; only the mean area of liver tumours (p = 0.034) and mean diameter of lung tumours (p = 0.021) differed significantly. No difference was observed between the methods. Inter-observer agreement was excellent (intra-class correlation >0.90) for all variables. In liver, overlaps of the 95% CI with the 95% CI of limits of PD or PR were observed for diameters above 22.7 and 37.9 mm, respectively. An overlap of 95% CIs was systematically observed for area. No overlaps were observed in lung. CONCLUSIONS: Although the experience of readers might not affect the precision of segmentation in lung and liver, the results of manual segmentation performed for tumour response assessment remain uncertain for large liver metastases.

Percutaneous thermal ablation of primary lung cancer.

Percutaneous ablation of small-size non-small-cell lung cancer (NSCLC) has demonstrated feasibility and safety in nonsurgical candidates. Radiofrequency ablation (RFA), the most commonly used technique, has an 80-90% reported rate of complete ablation, with the best results obtained in tumors less than 2-3cm in diameter. The highest one-, three-, and five-year overall survival rates reported in NSCLC following RFA are 97.7%, 72.9%, and 55.7% respectively. Tumor size, tumor stage, and underlying comorbidities are the main predictors of survival. Other ablation techniques such as microwave or cryoablation may help overcome the limitations of RFA in the future, particularly for large tumors or those close to large vessels. Stereotactic ablative radiotherapy (SABR) has its own complications and carries the risk of fiducial placement requiring multiple lung punctures. SABR has also demonstrated significant efficacy in treating small-size lung tumors and should be compared to percutaneous ablation.

Soft tissue masses with myxoid stroma: Can conventional magnetic resonance imaging differentiate benign from malignant tumors?

OBJECTIVES: To retrospectively evaluate the diagnostic performance of morphological signs observed on conventional magnetic resonance (MR) imaging to differentiate benign from malignant peripheral solid tumors of soft tissue with myxoid stroma. METHODS: MR images from 95 consecutive histopathologically proven tumors (26 benign and 69 malignant) of soft tissues with myxoid components were evaluated in our tertiary referral center. Two radiologists, blind to pathology results, independently reviewed conventional MR sequences including at least a) one T2-weighted sequence with or without fat suppression; b) one T1-weighted sequence without fat suppression; and c) one T1-weighted sequence with gadolinium-complex contrast enhancement and fat suppression. Multiple criteria were defined to analyze morphology, margins, architecture and tumor periphery and evaluated for each lesion. Intra- and inter-observer reproducibility and Odds ratios were calculated for each criterion. RESULTS: The most relevant and reproducible criteria to significantly predict malignancy were: (1) ill-defined tumor margins, (2) a hemorrhagic component, (3) intra-tumoral fat, (4) fibrosis and (5) the "tail sign". A lesion is classified as malignant if any of these 5 criteria is present, and benign if none of them are observed. Therefore, this combination provides a sensitivity of 92.9% and a specificity of 93.3%. CONCLUSION: Conventional MR imaging provides reproducible criteria that can be combined to differentiate between benign and malignant solid tumors of soft tissue with myxoid stroma.

[Bone metastases relapse after cementoplasty: Case report and discussion about the combination of radiotherapy and cementoplasty]. / Récidive tumorale osseuse locale après cimentoplastie: à propos d'un cas; discussion de l'intérêt de la radiothérapie après cimentoplastie.

Interventional radiology techniques - vertebroplasty, kyphoplasty and vertebroplasty - are part of the therapeutic arsenal in oncology. They are not, however, antitumoural by themselves. A combination of these techniques with an antitumoral treatment is thus required. We present the case of a patient with a spinal metastasis who received antitumor vertebroplasty without additional treatment. The follow-up has found a tumour development around the cement. This case illustrates the need for a complementary antitumor treatment following a consolidative procedure. Many combinations of treatment and techniques have been published; however, no study reached a sufficient proof of efficiency for any combination to be recommended. Prospective trials are needed to guide clinicians.

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.

Local treatment of metastases from differentiated thyroid cancer.

OBJECTIVES: To study the various local treatments available for thyroid cancer metastases, investigate techniques and assess their advantages and limitations and roles in the overall treatment strategy for metastatic disease. RESULTS: We investigated metastases surgery, external radiation therapy, embolization, chemoembolization, cementoplasty, radiofrequency ablation and cryotherapy, describing techniques, advantages and drawbacks and possible complications. Indications were reviewed according to metastases location, and the roles of the various techniques are discussed in the overall treatment strategy for thyroid cancer metastases. Despite the advent of new targeted therapies, local treatment still has an important role to play: either palliative or, in oligometastatic involvement, curative. Even in extensive disease, it may allow postponement of tyrosine kinase inhibitor therapy, which, once initiated, has to be continued life-long, is expensive and is not free of side-effects.

Hepar lobatum carcinomatosum associated with liver metastases from breast cancer: report of five cases.

BACKGROUNDS AND AIMS: Hepar lobatum carcinomatosum (HLC) is an exceptional acquired hepatic distortion which consists in irregularly lobulated hepatic contours seen in patients with known liver metastases, usually from breast carcinoma. We aimed to describe and analyze five similar cases of HLC resulting from metastatic mammary carcinoma in the liver and associated with rapid hepatic failure. METHODS: Five cases of HLC were investigated. Medical (including blood liver tests), radiological and histological data (2 cases) were collected and retrospectively analyzed. All patients were followed up for metastatic invasive ductal carcinoma of the breast and had a common pattern of treatment with combination of targeted therapies (bevacizumab, AVASTIN) and chemotherapy (paclitaxel, TAXOL). RESULTS: All the patients showed rapid hepatic failure after a mean of 9 courses of bevacizumab/paclitaxel. In all cases, liver imaging revealed liver capsule retraction and an irregular lobular margin. An apparent tumor regression of all liver metastases was showed in two cases. Biopsies were consistent with sinusoidal obstruction syndrome (SOS) and, surprisingly, no tumoral cells were found. CONCLUSION: Although rare, such an unusual pattern of liver metastasis may mimick acute cirrhosis and cause rapid hepatic failure in patients, despite possible apparent tumor regression on imaging. The etiology of this pathology is unclear, and may involve multiple pathogenic factors. Direct or indirect vascular injury plays an important role in the development of HLC.

Evaluation of percutaneous biopsies of renal masses under MRI-guidance: a retrospective study about 26 cases.

OBJECTIVE: To determine whether MRI allows safe and accurate guidance for biopsies of renal masses. MATERIALS AND METHODS: Between May 2010 and September 2013, 26 patients (15 men and 11 women) with 26 renal masses underwent MRI-guided percutaneous biopsy. For each patient, we retrospectively collected the epidemiological, procedural and histopathological data. RESULTS: Mean size of tumour was 3.6 cm (range 0.6 - 9 cm). Mean procedure time was 48 minutes (range 37 - 70 min). Malignancy was found in the percutaneous samples in 81 % (21/26) of the masses. All these cases were considered as true positive biopsies. Benignity was found in the percutaneous samples in 5/26 (19 %) of the masses but was confirmed only in 3 cases. The other 2 cases included one false negative case and one undetermined biopsy, as patient was lost to follow-up. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of this study were 95.4 %, 100 %, 100 %, 75 % and 96 %, respectively CONCLUSION: MRI-guidance is safe and accurate to target renal masses.

Update on the surgical management of Pott's disease.

One-third of the world's population is infected with Mycobacterium tuberculosis. Data reported in 2011 indicate, for the first time, a decline in cases of tuberculosis, despite persistent inequalities across geographic areas and increasing rates of drug resistance. Osteo-articular tuberculosis affects the spine in half the cases. Pharmacotherapy must be combined with surgery in patients with spinal cord or nerve root compression, large abscesses, or marked anterior column osteolysis with kyphosis and instability. The quality of debridement and bony fusion is optimal when the anterior approach is used. Posterior fixation is the best means of achieving reduction followed by stable sagittal alignment over time. New treatment strategies combine conventional surgical methods, closed interventional radiology procedures for drainage and spinal cord decompression, and percutaneous fixation.

Fracture in ankylosing spondylitis after minor trauma: radiological pitfalls and treatment by percutaneous instrumentation. A case report.

Patients with ankylosing spondylitis may experience spinal fractures even after minor injuries. The diagnosis of non-dislocated spinal fracture is based on clinical symptoms and radiological findings. Difficulties in interpreting the imaging studies can result in considerable diagnostic delays. We describe the steps of the radiological diagnosis in a patient with a fracture of L2 that was not visible on standard lumbar spine radiographs. Magnetic resonance imaging (MRI) T2 STIR sequences allowed determining the location and showed signs of a recent fracture. Then, MRI T1 images and computed tomography provided a detailed evaluation of the fracture line. In patients with ankylosing spondylitis, fracture instability is common, making surgical treatment mandatory. Open surgery is associated with substantial rates of infection and implant loosening. Percutaneous instrumentation has not yet been evaluated for the treatment of spinal fractures in patients with ankylosing spondylitis. This minimally invasive surgical technique enables multilevel internal fixation and may constitute an interesting alternative to open surgery.

[Percutaneous ablation of renal tumors: radiofrequency ablation or cryoablation?]. / Thermoablation percutanée des cancers rénaux : radiofréquence ou cryoablation?

Percutaneous ablation of renal tumors, including radiofrequency ablation and cryoablation, are increasingly being used for small tumors as an alternative to surgery for poor surgical candidates. Compared to radiofrequency ablation, cryoablation has several advantages: improved volume control and preservation of adjacent structures due to the excellent depiction of the ice ball on CT and MRI; better protection of the collecting system for central tumor with reduced risk of postprocedural urinary fistula. The main pitfall of cryoablation is the higher cost. Therefore, cryoablation should be reserved for the treatment of complex tumors. In this article, we will review the different steps of percutaneous renal tumor ablation procedures including patient selection, technical considerations, and follow-up imaging.

[Pain management in oncology]. / Traitement de la douleur en oncologie.

Several interventional radiology procedures are available for the management of cancer pain. In this article, we will briefly review the different procedures and their value in the setting of cancer pain management under two main categories: indirect action (regional anesthesia from neurolysis) and direct action on the tumor. Percutaneous ablation of bone tumors: alcohol, laser, radiofrequency, microwaves, ultrasound, and cryoablation. Several indications have previously been validated, including thermal ablation of bone metastases with results superior to conventional therapies. Additional applications should be validated over the next few years.

[Acute, hyperintense, and febrile cervicalgia. Crowned dens syndrome, a monofocal microcrystalline arthritis sometimes doubly misleading]. / Cervicalgies aiguës, hyperintenses et fébriles. Syndrome de la dent couronnée, une arthrite microcristalline monofocale parfois doublement trompeuse.

Microcrystalline arthritis sometimes have atypical localizations and presentations. The crowned dens syndrome, due to hydroxyapatite or calcium pyrophosphate deposits in peri-odontoid ligaments of the atlas, can provoke acute or chronic cervicalgia or misleading presentations such as meningitidis or fever of unknown origin. We present a particularly severe new case requesting urgent surgery, and a literature review to alert clinicians and prevent misdiagnosing this syndrome. Indeed, calcifications may be very discrete or just incidental and prevent a complete diagnostic approach.