Integrating interventional oncology in the treatment of liver tumors.

BACKGROUND: Percutaneous ablation techniques offer a vast armamentarium for local, minimally invasive treatment of liver tumors, nowadays representing an established therapeutic option, which is integrated in treatment algorithms, especially for non-resectable liver tumors. The results of ablative treatment compare very well to surgical treatment in liver lesions, and confirm that these techniques are a valuable option for bridging for transplantation. Different techniques have been established to perform tumor ablation, and the feasibility varies according to the procedure and technical skills of the operator, depending on the size and location of the liver lesion. In recent years, stereotactic multi-needle techniques using 3D trajectory planning, general anesthesia, and tube disconnection during needle placement have had a strong impact on the application range of ablation for liver tumors. CONCLUSION: It is well known that creating a sufficient ablation margin and overlapping ablation zones is one key issue to enable ablation of large liver lesions with tumor-free margins (A0 ablation in analogy to R0 resection). Image fusion during treatment and follow-up assure highly accurate staging procedures and interventional planning. NOVEL ASPECTS: Review on the standards in ablation techniques for the treatment of liver tumors. Update on different ablation techniques, indications, and contraindications for percutaneous liver tumor treatment. Summary of recently published reports on liver tumor ablation.

Influence of Ultra-Low-Dose and Iterative Reconstructions on the Visualization of Orbital Soft Tissues on Maxillofacial CT.

BACKGROUND AND PURPOSE: Dose reduction on CT scans for surgical planning and postoperative evaluation of midface and orbital fractures is an important concern. The purpose of this study was to evaluate the variability of various low-dose and iterative reconstruction techniques on the visualization of orbital soft tissues. MATERIALS AND METHODS: Contrast-to-noise ratios of the optic nerve and inferior rectus muscle and subjective scores of a human cadaver were calculated from CT with a reference dose protocol (CT dose index volume = 36.69 mGy) and a subsequent series of low-dose protocols (LDPs I-4: CT dose index volume = 4.18, 2.64, 0.99, and 0.53 mGy) with filtered back-projection (FBP) and adaptive statistical iterative reconstruction (ASIR)-50, ASIR-100, and model-based iterative reconstruction. The Dunn Multiple Comparison Test was used to compare each combination of protocols (α = .05). RESULTS: Compared with the reference dose protocol with FBP, the following statistically significant differences in contrast-to-noise ratios were shown (all, P ≤ .012) for the following: 1) optic nerve: LDP-I with FBP; LDP-II with FBP and ASIR-50; LDP-III with FBP, ASIR-50, and ASIR-100; and LDP-IV with FBP, ASIR-50, and ASIR-100; and 2) inferior rectus muscle: LDP-II with FBP, LDP-III with FBP and ASIR-50, and LDP-IV with FBP, ASIR-50, and ASIR-100. Model-based iterative reconstruction showed the best contrast-to-noise ratio in all images and provided similar subjective scores for LDP-II. ASIR-50 had no remarkable effect, and ASIR-100, a small effect on subjective scores. CONCLUSIONS: Compared with a reference dose protocol with FBP, model-based iterative reconstruction may show similar diagnostic visibility of orbital soft tissues at a CT dose index volume of 2.64 mGy. Low-dose technology and iterative reconstruction technology may redefine current reference dose levels in maxillofacial CT.

Comparison of Two Electromagnetic Navigation Systems For CT-Guided Punctures: A Phantom Study.

PURPOSE: We compared the targeting accuracy and reliability of two different electromagnetic navigation systems for manually guided punctures in a phantom. MATERIALS AND METHODS: CT data sets of a gelatin filled plexiglass phantom were acquired with 1, 3, and 5 mm slice thickness. After paired-point registration of the phantom, a total of 480 navigated stereotactic needle insertions were performed manually using electromagnetic guidance with two different navigation systems (Medtronic Stealth Station: AxiEM; Philips: PercuNav). A control CT was obtained to measure the target positioning error between the planned and actual needle trajectory. RESULTS: Using the Philips PercuNav, the accomplished Euclidean distances were 4.42 ±â€Š1.33 mm, 4.26 ±â€Š1.32 mm, and 4.46 ±â€Š1.56 mm at a slice thickness of 1, 3, and 5 mm, respectively. The mean lateral positional errors were 3.84 ±â€Š1.59 mm, 3.84 ±â€Š1.43 mm, and 3.81 ±â€Š1.71 mm, respectively. Using the Medtronic Stealth Station AxiEM, the Euclidean distances were 3.86 ±â€Š2.28 mm, 3.74 ±â€Š2.1 mm, and 4.81 ±â€Š2.07 mm at a slice thickness of 1, 3, and 5 mm, respectively. The mean lateral positional errors were 3.29 ±â€Š1.52 mm, 3.16 ±â€Š1.52 mm, and 3.93 ±â€Š1.68 mm, respectively. CONCLUSION: Both electromagnetic navigation devices showed excellent results regarding puncture accuracy in a phantom model. The Medtronic Stealth Station AxiEM provided more accurate results in comparison to the Philips PercuNav for CT with 3 mm slice thickness. One potential benefit of electromagnetic navigation devices is the absence of visual contact between the instrument and the sensor system. Due to possible interference with metal objects, incorrect position sensing may occur. In contrast to the phantom study, patient movement including respiration has to be compensated for in the clinical setting. KEY POINTS: • Commercially available electromagnetic navigation systems have the potential to improve the therapeutic range for CT guided percutaneous procedures by comparing the needle placement accuracy on the basis of planning CT data sets with different slice thickness. Citation Format: • Putzer D, Arco D, Schamberger B et al. Comparison of Two Electromagnetic Navigation Systems For CT-Guided Punctures: A Phantom Study. Fortschr Röntgenstr 2016; 188: 470 - 478.

Ultralow-dose computed tomography imaging for surgery of midfacial and orbital fractures using ASIR and MBIR.

The influence of dose reductions on diagnostic quality using a series of high-resolution ultralow-dose computed tomography (CT) scans for computer-assisted planning and surgery including the most recent iterative reconstruction algorithms was evaluated and compared with the fracture detectability of a standard cranial emergency protocol. A human cadaver head including the mandible was artificially prepared with midfacial and orbital fractures and scanned using a 64-multislice CT scanner. The CT dose index volume (CTDIvol) and effective doses were calculated using application software. Noise was evaluated as the standard deviation in Hounsfield units within an identical region of interest in the posterior fossa. Diagnostic quality was assessed by consensus reading of a craniomaxillofacial surgeon and radiologist. Compared with the emergency protocol at CTDIvol 35.3 mGy and effective dose 3.6 mSv, low-dose protocols down to CTDIvol 1.0 mGy and 0.1 mSv (97% dose reduction) may be sufficient for the diagnosis of dislocated craniofacial fractures. Non-dislocated fractures may be detected at CTDIvol 2.6 mGy and 0.3 mSv (93% dose reduction). Adaptive statistical iterative reconstruction (ASIR) 50 and 100 reduced average noise by 30% and 56%, and model-based iterative reconstruction (MBIR) by 93%. However, the detection rate of fractures could not be improved due to smoothing effects.

Substantial dose reduction in modern multi-slice spiral computed tomography (MSCT)-guided craniofacial and skull base surgery.

PURPOSE: Reduction of the radiation exposure involved in image-guided craniofacial and skull base surgery is an important goal. The purpose was to evaluate the influence of low-dose protocols in modern multi-slice spiral computed tomography (MSCT) on target registration errors (TREs). MATERIALS AND METHODS: An anthropomorphic skull phantom with target markers at the craniofacial bone and the anterior skull base was scanned in Sensation Open (40-slice), LightSpeed VCT (64-slice) and Definition Flash (128-slice). Identical baseline protocols (BP) at 120  kV/100  mAs were compared to the following low-dose protocols (LD) in care dose/dose modulation: (LD-I) 100  kV/35ref. mAs, (LD-II) 80  kV/40 - 41ref. mAs, and (LD-III) 80  kV/15 - 17ref. mAs. CTDIvol and DLP were obtained. TREs using an optical navigation system were calculated for all scanners and protocols. Results were statistically analyzed in SPSS and compared for significant differences (p ≤ 0.05). RESULTS: CTDIvol for the Sensation Open/LightSpeed VCT/Definition Flash showed: (BP) 22.24 /32.48 /14.32 mGy; (LD-I) 4.61 /3.52 /1.62 mGy; (LD-II) 3.15 /2.01 /0.87 mGy; and (LD-III) na/0.76 /0.76 mGy. Differences between the BfS (Bundesamt für Strahlenschutz) reference CTDIvol of 9 mGy and the lowest CTDIvol were approximately 3-fold for Sensation Open, and 12-fold for the LightSpeed VCT and Definition Flash. A total of 33 registrations and 297 TRE measurements were performed. In all MSCT scanners, the TREs did not significantly differ between the low-dose and the baseline protocols. CONCLUSION: Low-dose protocols in modern MSCT provided substantial dose reductions without significant influence on TRE and should be strongly considered in image-guided surgery.

[Magnetic resonance imaging of radiofrequency current-induced coagulation zones in the ex vivo bovine liver]. / Magnetresonanztomografie von durch Radiofrequenzablation erzeugten Koagulationszonen in der Ex-vivo-Rinderleber.

PURPOSE: To compare different magnetic resonance imaging sequences for correct representation and discrimination between non-ablated, partially ablated, and completely ablated tissue after radiofrequency ablation (RFA) in the ex vivo, non-perfused bovine liver model. MRI is the method of choice for imaging of the induced coagulation zones ex vivo. However, the optimal imaging sequence has not been determined yet. MATERIALS AND METHODS: RFA, which is a method to locally destroy malignant cells with heat and which has been established for the treatment of non-resectable liver tumors, was applied to bovine livers. After the RF ablation procedure, the livers were sliced for visual inspection of the coagulation zones. As a result, non-ablated, partially ablated, and completely ablated tissues were distinguished. For the subsequent MR imaging, markers were used to indicate the borders of the different zones. For every imaging sequence the tissue representation at the site of these markers was classified as "exact", "overestimating", "underestimating" and "not determinable". Additionally, T 1, T 2, and proton density (PD) maps were measured. RESULTS: It was found that both T 1 and T 2 values gradually decrease from non-ablated to ablated tissue, with T 1 showing a stronger relative change compared to T 2. For PD no change was observed between non-ablated and partially ablated tissue and a clear decrease was detected for the completely ablated zone. CONCLUSION: Sequences with a strong PD influence resulted in the highest accuracy for discrimination between completely ablated and partially ablated tissue. The differences in image quality and contrast could be explained by the observed T 1, T 2 and PD changes.