Percutaneous laser ablation of metastatic lymph nodes in the neck from papillary thyroid carcinoma: preliminary results.

CONTEXT: Percutaneous laser ablation (PLA) may be useful in treating patients with metachronous metastatic lymph nodes in the neck. OBJECTIVE: Our objective was to assess PLA as a treatment of difficult-to-treat metachronous cervical lymph node metastases from papillary thyroid carcinoma. DESIGN AND SETTING: We conducted a retrospective analysis of prospectively collected data at a public hospital. PATIENTS: Fifteen patients with previous resection of papillary thyroid carcinoma with elevated serum levels of thyroglobulin (Tg) or anti-Tg antibodies (TgAbs) and 24 metachronous nodal metastases treated between September 2010 and April 2012 were followed with [¹8F]fluorodeoxyglucose (¹8FDG) positron emission tomography (PET)/computed tomography (CT) and contrast-enhanced ultrasound (CEUS). INTERVENTION: Intervention was PLA. OUTCOME MEASURES: Technique feasibility and technical success were evaluated. Tg/TgAb serum levels and ¹8FDG-PET/CT, and CEUS appearance were assessed at 6 and 12 months and compared with baseline. Complications were recorded. RESULTS: PLA was always feasible, and technical success was achieved in all patients. At 6 months, local control was achieved in 11 of 15 patients (73%), with 6 (40%) having serum Tg/TgAb normalized (P = .017 vs baseline). Whereas 20 of 24 (83%) nodes were negative at ¹8FDG-PET/CT and CEUS (P < .001 vs baseline), 4 were ¹8FDG-PET/CT-positive (3 also CEUS-positive). At the 12-month follow-up, local control was achieved in 10 of 14 patients (71.4%). Sixteen of 20 nodes (80%) were negative at ¹8FDG-PET/CT and CEUS (P < .001 vs baseline), 4 were ¹8FDG-PET/CT-positive (2 also CEUS-positive). Four of 10 (40%) patients had normalization of serum Tg/TgAb (P = .098 vs baseline). No major complications occurred. CONCLUSIONS: PLA is potentially feasible, safe, and effective for the treatment of metachronous cervical nodal metastases from papillary thyroid carcinoma. This procedure may reduce or delay a large number of highly invasive repeat neck dissections.

Extrahepatic recurrence and second malignancies after treatment of hepatocellular carcinoma: spectrum of imaging findings.

PURPOSE: To describe diagnostic imaging features (with a focus on CT findings) of extrahepatic relapses of treated hepatocellular carcinoma and to propose a post-treatment follow-up protocol. MATERIAL AND METHODS: During a six-year span, 226 patients (aged 32-88 years) with chronic hepatitis/cirrhosis were diagnosed as having hepatocellular carcinoma confined to the liver and treated percutaneously with radiofrequency (RF) ablation. A total of 313 treatment sessions were performed. Post-therapeutic follow-up is based upon clinical evaluation, laboratory and imaging (with CT holding the key role) studies. RESULTS: Mean duration of follow-up was 17 months. After successful treatment, actuarial probability of neoplastic relapse is 30.7% after 1 year and 58.5% after 2 years. Eighty-eight patients had recurrence of hepatocellular carcinoma after a variable time interval (mean 7.3 months). Extrahepatic neoplastic relapse was observed in 14 patients, half of these without active hepatic disease. Distribution of extrahepatic sites of recurrence was as follows: abdominal lymph nodes (6 cases), bone (3), peritoneum (2), adrenal (2), lung (1). Five patients (2.2%) had a second primary neoplasm. CONCLUSIONS: Extrahepatic hepatocellular carcinoma is uncommon and occurs in advanced stages, but may represent a pattern of post-treatment relapse. The distinctive hypervascularity of this tumour histology may be observed in adenopathies and adrenal metastases. Second primary neoplasms should be considered in the differential diagnosis of lesions observed during follow-up.

Percutaneous radio-frequency ablation of hepatic metastases from colorectal cancer: long-term results in 117 patients.

PURPOSE: To describe the results of an ongoing radio-frequency (RF) ablation study in patients with hepatic metastases from colorectal carcinoma. MATERIALS AND METHODS: In 117 patients, 179 metachronous colorectal carcinoma hepatic metastases (0.9-9.6 cm in diameter) were treated with RF ablation by using 17-gauge internally cooled electrodes. Computed tomographic follow-up was performed every 4-6 months. Recurrent tumors were retreated when feasible. Time to new metastases and death for each patient and time to local recurrence for individual lesions were modeled with Kaplan-Meier analysis. Modeling determined the effect of number of metastases on the time to new metastases and death and effect of tumor size on local recurrence. RESULTS: Estimated median survival was 36 months (95% CI; 28, 52 months). Estimated 1, 2, and 3-year survival rates were 93%, 69%, and 46%, respectively. Survival was not significantly related to number of metastases treated. In 77 (66%) of 117 patients, new metastases were observed at follow-up. Estimated median time until new metastases was 12 months (95% CI; 10, 18 months). Percentages of patients with no new metastases after initial treatment at 1 and 2 years were 49% and 35%, respectively. Time to new metastases was not significantly related to number of metastases. Seventy (39%) of 179 lesions developed local recurrence after treatment. Of these, 54 were observed by 6 months and 67 by 1 year. No local recurrence was observed after 18 months. Frequency and time to local recurrence were related to lesion size (P < or =.001). CONCLUSION: RF ablation is an effective method to treat hepatic metastases from colorectal carcinoma.

Percutaneous radio-frequency ablation of liver metastases from breast cancer: initial experience in 24 patients.

PURPOSE: To evaluate the authors' initial experience in a consecutive series of 24 patients with breast cancer liver metastases treated with radio-frequency (RF) ablation. MATERIALS AND METHODS: Twenty-four consecutive patients with 64 metastases measuring 1.0--6.6 cm in diameter (mean, 1.9 cm) underwent ultrasonography-guided percutaneous RF ablation with 18-gauge, internally cooled electrodes. Treatment was performed with the patient under conscious sedation and analgesia or general anesthesia. A single lesion was treated in 16 patients, and multiple lesions were treated in eight patients. Follow-up with serial computed tomography ranged from 4 to 44 months (mean, 10 months; median, 19 months). RESULTS: Complete necrosis was achieved in 59 (92%) of 64 lesions. Among the 59 lesions, complete necrosis required a single treatment session in 58 lesions (92%) and two treatment sessions in one lesion (2%). In 14 (58%) of 24 patients, new metastases developed during follow-up. Ten (71%) of these 14 patients developed new liver metastases. Currently, 10 (63%) of 16 patients whose lesions were initially confined to the liver are free of disease. One patient died of progressive brain metastases. No major complications occurred. Two minor complications were observed. CONCLUSION: On the basis of preliminary study results, percutaneous RF ablation appears to be a simple, safe, and effective treatment for focal liver metastases in selected patients with breast cancer.

Radiofrequency thermal ablation of hepatic metastases.

Percutaneous radiofrequency (RF) ablation is a promising therapeutic option for liver metastases, which may result in prolonged survival and chance for cure. Recent technological advancements provide larger coagulation volumes, allowing treatment of medium- and large-size metastases. Candidates are patients with metachronous liver metastases from colorectal or other primary cancers, in whom surgery is contraindicated and with one to four nodules each smaller than approx. 4 cm. We treated 109 patients with 172 colorectal metastases in the liver. Local control was obtained in 70.4% of lesions. Recurrence was significantly more frequent in lesions >3 cm. One major complication occurred (0.6% of sessions), a large bowel perforation requiring surgery. Seven minor complications did not require therapy. New metastases developed at follow-up in 50.4% of patients. Survival rates are 67% and 33% after 2 and 3 years, respectively; estimated median survival being 30 months. RF ablation advantages include minimal-invasiveness (no mortality, significantly lower complications), reduced costs and hospital stays compared to surgery, feasibility in non-surgical candidates, and the potential of repeated treatment if local recurrence occurs or new metastases develop.

Hepatocellular carcinoma: radio-frequency ablation of medium and large lesions.

PURPOSE: To study local therapeutic efficacy, side effects, and complications of radio-frequency (RF) ablation in the treatment of medium and large hepatocellular carcinoma (HCC) lesions in patients with cirrhosis or chronic hepatitis. MATERIALS AND METHODS: One-hundred fourteen patients who were under conscious sedation or general anesthesia had 126 HCCs greater than 3.0 cm in diameter treated with RF by using an internally cooled electrode. Eighty tumors were medium (3.1-5.0 cm), and 46 were large (5.1-9.5 cm). The mean diameter for all tumors was 5.4 cm. At imaging, 75 tumors were considered noninfiltrating, and 51 were considered infiltrating. RESULTS: Complete necrosis was attained in 60 lesions (47.6%), nearly complete (90%-99%) necrosis in 40 lesions (31.7%), and partial (50%-89%) necrosis in the remaining 26 lesions (20.6%). Medium and/or noninfiltrating tumors were treated successfully significantly more often than large and/or infiltrating tumors. Two major complications (death, hemorrhage requiring laparotomy) and five minor complications (self-limited hemorrhage, persistent pain) were observed. The single death was due to a break in sterile technique rather than to the RF procedure itself. CONCLUSION: RF ablation appears to be an effective, safe, and relatively simple procedure for the treatment of medium and large HCCs.

Liver cancer imaging: the need for accurate detection of intrahepatic disease spread.

The last ten years have seen dramatic changes in the therapeutic approach to both primary (i.e., hepatocellular carcinoma: HCC) and secondary (i.e., metastatic lesions) focal liver malignancies. This has been due to the increasing proliferation of new modalities, including percutaneous ablative therapies (ethanol injection: PEI; radiofrequency: RF; laser; microwaves), angiographic therapies (segmental chemoembolization; hypoxic perfusion) and liver transplantation (OLT), in addition to a greater acceptance of pre-existing modalities (resection; systemic chemotherapy). Thus, a main aim of current medical management is to select for each patient the therapeutic modality which will provide the highest success rate, fewest risks and lowest costs for each given situation. However, in order to decide on the appropriate therapeutic choice, the accurate diagnosis of neoplastic lesions by means of one or more imaging modalities (ultrasound: US; computed tomography: CT; magnetic resonance: MR) is mandatory. This imaging work-up can be viewed as having three purposes: lesion detection, lesion characterization, intrahepatic and extrahepatic cancer staging. The present paper is concerned primarily with the imaging approach to liver lesion detection.

Percutaneous ethanol injection of autonomously functioning thyroid nodule.

Percutaneous ethanol injection (PEI) is proposed for treatment of autonomously functioning thyroid nodule, especially for small-mid-sized solitary nodules, for patients refusing the other methods or not proving responsive to radioiodine, or for patients with non toxic nodule. The injection is performed under color Doppler sonography guidance, evaluating the most vascularized areas of the tumor where to primarily inject ethanol solution with 21-22 gauge needles. Serum TSH, FT4, FT3 and TG levels are measured before each treatment session and 3,6,12,24 and 36 months after the end of therapy. Complete remission was achieved by different authors in 86% of cases and the efficacy of response was shown to be inversely proportional to the nodule volume. When TSH remains undetectable, a second cycle of PEI can be performed. If there is complete lack of blood flow signals on color or power Doppler with persisting thyroid hyperfunction, sonographic contrast media can be administered i.v. to assess residual areas of intranodal hypervascularity. In patients with unsuppressed TSH levels before treatment, hormonal changes cannot be used as marker response. Disappearance of nodular hypervascularity at color Doppler sonography and complete normalization of the scintigraphic pattern is usually observed in all cases. PEI is generally well tolerated; no recurrences of the disease and no cases of hypothyroidism have been reported.

Radio-frequency ablation of hepatic metastases: postprocedural assessment with a US microbubble contrast agent--early experience.

PURPOSE: To evaluate contrast agent-enhanced ultrasonography (US) in the detection of untreated tumor after radio-frequency (RF) ablation of hepatic metastases. MATERIALS AND METHODS: Twenty patients with solitary colorectal liver metastases underwent percutaneous RF tumor ablation. Pre- and postablation imaging was performed with nonenhanced and enhanced color and power Doppler US and contrast-enhanced helical computed tomography (CT). Initial follow-up CT and US were performed 24 hours after ablation. The findings at US and CT were compared. RESULTS: Nonenhanced US demonstrated intratumoral signal in 15 of 20 metastases before ablation. This signal increased after contrast agent administration. Contrast-enhanced US performed 24 hours after ablation demonstrated residual foci of enhancement in three tumors, whereas no US signals were seen in any tumor on nonenhanced scans. CT demonstrated small (< 3-mm) persistent foci of residual enhancement in these three tumors and in three additional lesions that were not seen at US (US sensitivity, 50%; specificity, 100%; diagnostic agreement with CT, 85%). All six patients with evidence of residual tumor underwent repeat RF ablation. CONCLUSION: Contrast-enhanced US may depict residual tumor after RF application and thereby enable additional directed therapy. The potential reduction in treatment sessions and/or ancillary imaging procedures might increase the ease and practicality of percutaneous ablation of focal hepatic metastases.