Radiographic Local Tumor Control and Pain Palliation of Sarcoma Metastases within the Musculoskeletal System with Percutaneous Thermal Ablation.

PURPOSE: To evaluate the effectiveness of percutaneous image-guided thermal ablation in achieving local tumor control and pain palliation of sarcoma metastases within the musculoskeletal system. MATERIALS AND METHODS: Retrospective review of 64 sarcoma metastases within the musculoskeletal system in 26 women and 15 men (total = 41) treated with ablation between December 2011 and August 2016 was performed. Mean age of the cohort was 42.9 years ± 16.0 years. Two subgroups were treated: oligometastatic disease (n = 13) and widely metastatic disease (n = 51). A variety of sarcoma histologies were treated with average tumor volume of 42.5 cm3 (range 0.1-484.7 cm3). Pain scores were recorded before and 4 weeks after therapy for 59% (38/64) of treated lesions. Follow-up imaging was evaluated for local control and to monitor sites of untreated disease as an internal control. Fifty-eight percent (37/64) were lost to imaging follow-up at varying time points over a year. Complication rate was 5% (3/64; one minor and two major events). RESULTS: One-year local tumor control rates were 70% (19/27) in all patients, 67% (12/18) in the setting of progression of untreated metastases, and 100% (10/10) in the setting of oligometastatic disease. Median pain scores decreased from 8 (interquartile range 5.0-9.0) to 3 (interquartile range 0.1-4.0) 1 month after the procedure (P < 0.001). CONCLUSION: Image-guided percutaneous ablation is an effective option for local tumor control and pain palliation of metastatic sarcomas within the musculoskeletal system. Treatment in the setting of oligometastatic disease offers potential for remission. LEVEL OF EVIDENCE: Level 4, Retrospective Review.

Correction to: Treatment of Osteoid Osteomas Using a Navigational Bipolar Radiofrequency Ablation System.

In "Radiofrequency Ablation Procedure" section of the original article, the relationship between the location of the thermocouples and the size of the ablation zones is inaccurate and not consistent with the referenced article in the bibliography (#3. Hillen et al).

Neuroimaging Features of Idiopathic Intracranial Hypertension Persist After Resolution of Papilloedema.

Papilloedema is a key clinical finding in the diagnosis of idiopathic intracranial hypertension (IIH). However, newly proposed criteria allow diagnosis without papilloedema only if certain neuroimaging features are present. It is currently unclear if these findings persist upon resolution of papilloedema and IIH. A retrospective chart review identified three groups of patients (six per group) who had received orbital imaging within 4 weeks of fundoscopic examination: (1) IIH patients without active papilloedema, (2) IIH patients with active papilloedema, and (3) patients with no history of IIH or papilloedema. All magnetic resonance imaging (MRI) scans were graded by a neuroradiologist who was blinded to clinical status. Neuroimaging features were compared by using the Kruskal-Wallis one-way analysis of variance. Measurements of sellar and optic nerve configuration showed a statistical trend with papilloedema status. For the control group versus the active papilloedema group, the values were 0.0597 and 0.0621, respectively. For the control group versus the resolved papilloedema group, the values were 0.0485 and 0.0512, respectively. However, globe and sellar p values for the resolved papilloedema group versus the active papilloedema group were 1.000 and 0.6023, respectively, and not significant. Sellar and globe configuration suggest that a statistical trend for persistence after papilloedema has resolved and intracranial pressure (ICP) has normalised. Careful clinical correlation and fundus examination are essential because some of these neuroimaging features can be seen in normal patients and those with resolved IIH, and their presence on MRI may not necessarily indicate active disease or elevated ICP.

Drill-Assisted Biopsy of the Axial and Appendicular Skeleton: Safety, Technical Success, and Diagnostic Efficacy.

The purpose of this study was to evaluate the safety, technical success rate, and diagnostic efficacy of drill-assisted axial and appendicular bone biopsies. During a 3-y period, 703 drill-assisted biopsies were performed. The cohort included 54.2% men, with a mean age of 57.6 y ± 17.1. Median lesion volume was 10.9 mL (interquartile range, 3.4-30.2 mL). Lesions were lytic (31.7%), sclerotic (21.2%), mixed lytic and sclerotic (27.7%), or normal radiographic bone quality (19.3%). No complications were reported. The technical biopsy success rate was 99.9%. Crush artifact was present in 5.8% of specimens submitted for surgical pathologic examination, and 2.1% of specimens were inadequate for histologic evaluation.

Fluoroscopy-Guided Percutaneous Vertebral Body Biopsy Using a Novel Drill-Powered Device: Technical Case Series.

BACKGROUND: A novel coaxial biopsy system powered by a handheld drill has recently been introduced for percutaneous bone biopsy. This technical note describes our initial experience performing fluoroscopy-guided vertebral body biopsies with this system, compares the yield of drill-assisted biopsy specimens with those obtained using a manual technique, and assesses the histologic adequacy of specimens obtained with drill assistance. METHODS: Medical records of all single-level, fluoroscopy-guided vertebral body biopsies were reviewed. Procedural complications were documented according to the Society of Interventional Radiology classification. The total length of bone core obtained from drill-assisted biopsies was compared with that of matched manual biopsies. Pathology reports were reviewed to determine the histologic adequacy of specimens obtained with drill assistance. RESULTS: Twenty eight drill-assisted percutaneous vertebral body biopsies met study inclusion criteria. No acute complications were reported. Of the 86 % (24/28) of patients with clinical follow-up, no delayed complications were reported (median follow-up, 28 weeks; range 5-115 weeks). The median total length of bone core obtained from drill-assisted biopsies was 28 mm (range 8-120 mm). This was longer than that obtained from manual biopsies (median, 20 mm; range 5-45 mm; P = 0.03). Crush artifact was present in 11 % (3/28) of drill-assisted biopsy specimens, which in one case (3.6 %; 1/28) precluded definitive diagnosis. CONCLUSIONS: A drill-assisted, coaxial biopsy system can be used to safely obtain vertebral body core specimens under fluoroscopic guidance. The higher bone core yield obtained with drill assistance may be offset by the presence of crush artifact.

Fluoroscopy-guided intervertebral disc biopsy with a coaxial drill system.

OBJECTIVES: Percutaneous biopsy of discitis-osteomyelitis is performed to isolate the causative microorganism and exclude alternative diagnoses. We compared drill-assisted and manual fluoroscopy-guided intervertebral disc biopsies with respect to conscious sedation requirements and histologic quality of obtained specimens. MATERIALS AND METHODS: Medical records of all single-level, fluoroscopy-guided intervertebral disc biopsies supervised by one of two musculoskeletal radiologists between January 2010 and March 2015 were reviewed. Duration and cumulative medication doses required for each biopsy were recorded. Pathology reports were reviewed to determine whether the obtained specimens were adequate for histopathologic evaluation. Microbiology reports were reviewed to determine whether the causative organism was isolated from the biopsy specimen. RESULTS: During the study period, 21 drill-assisted and 20 manual biopsies were performed. The median duration of conscious sedation for drill-assisted biopsies was 30 min (range, 17-40 min) compared with 39 min (range, 20-90 min) for manual biopsies (p < 0.01). Drill-assisted biopsies also required lower median cumulative doses of intravenous midazolam [2 mg (range, 0-5 mg) vs. 3 mg (range, 0-9 mg); p = 0.02]. All drill-assisted biopsy specimens were adequate for histopathologic evaluation. One manual biopsy specimen (5 %; 1/20) was inadequate for histopathologic evaluation owing to crush artifact. The microbiology yields of drill-assisted and manual biopsies were comparable [14 % (3/21) vs. 20 % (4/20); p = 0.62]. CONCLUSIONS: Fluoroscopically-guided intervertebral disc biopsies performed with drill assistance require less conscious sedation compared with manual biopsies and yield specimens that are adequate for histopathologic evaluation.

Treatment of Osteoid Osteomas Using a Navigational Bipolar Radiofrequency Ablation System.

BACKGROUND: Percutaneous CT-guided radiofrequency ablation is a safe and effective minimally invasive treatment for osteoid osteomas. This technical case series describes the use of a recently introduced ablation system with a probe that can be curved in multiple directions, embedded thermocouples for real-time monitoring of the ablation volume, and a bipolar design that obviates the need for a grounding pad. METHODS: Medical records of all patients who underwent radiofrequency ablation of an osteoid osteoma with the STAR Tumor Ablation System (DFINE; San Jose, CA) were reviewed. The location of each osteoid osteoma, nidus volume, and procedural details were recorded. Treatment efficacy and long-term complications were assessed at clinical follow-up. RESULTS: During the study period, 18 osteoid osteomas were radiofrequency ablated with the multidirectional bipolar system. Lesion locations included the femur (50%; 9/18), tibia (22%; 4/18), cervical spine (11%; 2/18), calcaneus (5.5%; 1/18), iliac bone (5.5%; 1/18), and fibula (5.5%; 1/18). The median nidus volume of these cases was 0.33 mL (range 0.12-2.0 mL). All tumors were accessed via a single osseous channel. Median cumulative ablation time was 5 min and 0 s (range 1 min and 32 s-8 min and 50 s). All patients with clinical follow-up reported complete symptom resolution. No complications occurred. CONCLUSION: Safe and effective CT-guided radiofrequency ablation of osteoid osteomas can be performed in a variety of locations using a multidirectional bipolar system.

Combination acetabular radiofrequency ablation and cementoplasty using a navigational radiofrequency ablation device and ultrahigh viscosity cement: technical note.

BACKGROUND: Percutaneous radiofrequency ablation and cementoplasty is an alternative palliative therapy for painful metastases involving axial load-bearing bones. This technical report describes the use of a navigational radiofrequency probe to ablate acetabular metastases from an anterior approach followed by instillation of ultrahigh viscosity cement under CT-fluoroscopic guidance. MATERIALS AND METHODS: The tumor ablation databases of two institutions were retrospectively reviewed to identify patients who underwent combination acetabular radiofrequency ablation and cementoplasty using the STAR Tumor Ablation and StabiliT Vertebral Augmentation Systems (DFINE; San Jose, CA). Pre-procedure acetabular tumor volume was measured on cross-sectional imaging. Pre- and post-procedure pain scores were measured using the Numeric Rating Scale (10-point scale) and compared. Partial pain improvement was categorically defined as ≥ 2-point pain score reduction. Patients were evaluated for evidence of immediate complications. Electronic medical records were reviewed for evidence of delayed complications. RESULTS: During the study period, 12 patients with acetabular metastases were treated. The median tumor volume was 54.3 mL (range, 28.3-109.8 mL). Pre- and post-procedure pain scores were obtained from 92% (11/12) of the cohort. The median pre-procedure pain score was 8 (range, 3-10). Post-procedure pain scores were obtained 7 days (82%; 9/11), 11 days (9.1%; 1/11) or 21 days (9.1%; 1/11) after treatment. The median post-treatment pain score was 3 (range, 1-8), a statistically significant difference compared with pre-treatment (P = 0.002). Categorically, 73% (8/11) of patients reported partial pain relief after treatment. No immediate symptomatic complications occurred. Three patients (25%; 3/12) were discharged to hospice within 1 week of treatment. No delayed complications occurred in the remaining 75% (9/12) of patients during median clinical follow-up of 62 days (range, 14-178 days). CONCLUSIONS: Palliative percutaneous acetabular radiofrequency ablation and cementoplasty can be feasibly performed from an anterior approach using a navigational ablation probe and ultrahigh viscosity cement instilled under CT-fluoroscopic guidance.

CT-guided percutaneous skull biopsy using a drill-assisted system: Technical report of two cases.

The OnControl coaxial biopsy system (Vidacare Corporation, Shavano Park, TX) includes an inner diamond-tipped access needle and hollow biopsy needle that engage with a battery-powered hand drill. Herein, we report the use of this novel device to perform two CT-guided percutaneous skull biopsies. Both procedures were performed without complication and facilitated a pathologic diagnosis.

Delayed vertebral body collapse after stereotactic radiosurgery and radiofrequency ablation: Case report with histopathologic-MRI correlation.

Stereotactic radiosurgery and percutaneous radiofrequency ablation are emerging therapies for pain palliation and local control of spinal metastases. However, the post-treatment imaging findings are not well characterized and the risk of long-term complications is unknown. We present the case of a 46-year-old woman with delayed vertebral body collapse after stereotactic radiosurgery and radiofrequency ablation of a painful lumbar metastasis. Histopathologic-MRI correlation confirmed osteonecrosis as the underlying etiology and demonstrated that treatment-induced vascular fibrosis and tumor progression can have identical imaging appearances.

Drill-assisted, fluoroscopy-guided vertebral body access for radiofrequency ablation: Technical case series.

Radiofrequency ablation is a valuable therapy for palliation of painful spinal metastases and local tumor control; however, accessing the vertebral body can be difficult and time consuming with traditional manual needles. Herein, we report our initial experience using a drill-assisted, fluoroscopy-guided technique for accessing the vertebral body for radiofrequency ablation.

Substituted 2,2'-bipyrroles and pyrrolylfurans via intermediate isoxazolylpyrroles.

We describe a new synthesis of the 3-chloro-(4'-methoxy)-2,2'-pyrrolylfuran segment (3) of (+)- roseophilin. The route exploits a isoxazoylpyrrole intermediate, wherein the isoxazole ring serves as a ß-diketone equivalent and a directing group for palladium catalyzed chlorination of the attached pyrrole. Subsequent reduction of the N-O bond and acid promoted cyclization afords roseophilin segment 3b in five steps and 19% overall yield. This strategy was extended to the synthesis of 3-chloro-(4'-alkoxy)-2,2'-pyrrolylfurans (16a-c) and 4-alkoxy-2,2'-bipyrroles (20a-c), which are building blocks to synthesize bioactive prodiginine natural products and their congeners.