Percutaneous image-guided cryoablation: current applications and results in the oncologic field

Percutaneous imaging-guided cryoablation (PICA) is a recently developed technique, which applies extreme hypothermia to destroy tumours under close imaging surveillance. It is minimally invasive, safe, repeatable, and does not interrupt or compromise other oncologic therapies. It presents several advantages over more established heat-based thermal ablation techniques (e.g. radiofrequency ablation; RFA) including intrinsic analgesic properties, superior monitoring capability on multi-modal imaging, ability to treat larger tumours, and preservation of tissue collagenous architecture. There has been a recent large increase in reports evaluating the utility of PICA in a wide range of patients and tumours, but systematic analysis of the literature is challenging due to the rapid pace of change and predominance of extensively heterogeneous level III studies. The precise onco-therapeutic role of PICA has not been established. This narrative review outlines the available evidence for PICA in a range of tumours. Current indications include curative therapy of small T1a renal tumours; curative/palliative therapy of small primary/secondary lung tumours where RFA is unsuitable; palliation of painful bone metastases; and urologic treatment of organ-confined prostate cancer. There is growing evidence to support its use for small hepatic tumours, and encouraging results have been obtained for breast tumours, extra-abdominal desmoid tumours, and management of higher-stage tumours and oligometastatic disease. However, the overall evidence base is weak, effectively restricting PICA to cases where standard therapy and RFA are unsuitable. As the technique and evidence continue to mature, the benefits of this emerging technique will hopefully become more widely available to cancer patients in the future.     

Gabapentin treatment of glossopharyngeal neuralgia: a follow-up of four years of a single case.

Glossopharyngeal neuralgia causes intermittent, lancinanting pain, involving the posterior tongue and pharynx, with radiation to deep ear structures. There are different pharmacological therapies which are tried to treat the neuralgia: carbamazepin, phenytoin, diazepam, amytriptyline, phenobarbital, ketamine, and baclofen; there are also surgical treatment proposed in order to cure the neuralgia such as vascular decompression or electrical stimulation of the motor cortex controlateral to the pain area. We report a single case of a patient with glossopharyngeal neuralgia treated with Gabapentin, the first described, who was followed up for four years, who respond completely to the therapy and did not complain from side effects, reducing even the reminiscence of pain during the second cluster of crisis.     

A highly accurate method for monitoring histological recovery in patients with celiac disease on a gluten-free diet using an endoscopic approach that avoids the need for biopsy: a double-center study

BACKGROUND AND STUDY AIM: Endoscopy with duodenal biopsy is often performed in order to assess histological recovery in patients with celiac disease who are on a gluten-free diet. Use of the "immersion" technique during upper endoscopy allows visualization of duodenal villi or detection of total villous atrophy. In this two-center study, we investigated the accuracy of the immersion technique in predicting histological recovery in patients on a gluten-free diet whose initial diagnosis of celiac disease had been made on the basis of total villous atrophy. PATIENTS AND METHODS: The immersion technique was performed in 62 patients with celiac disease who were being treated and who had been referred for follow-up (26 patients at the Rome center and 36 patients at the Vicenza center). All these patients had an initial diagnosis based on positive antibodies and biopsy-proved duodenal total villous atrophy. At the follow-up examination, the duodenal villi were re-evaluated as present or absent by one endoscopist at each center, and the results were compared with the histology. RESULTS: At the follow-up endoscopy, the duodenal villi were found to be present in 51 patients and absent in 11. The sensitivity, specificity, positive predictive value, and negative predictive value of the immersion technique for detecting the presence or absence of villi were all 100 %. CONCLUSIONS: This study demonstrated the feasibility and the high level of accuracy of the immersion technique in predicting the histological recovery of duodenal villi in patients with celiac disease who are following a gluten-free diet. An endoscopy-based approach that avoids the need for biopsy could be useful for monitoring the dietary adherence and/or response of patients with an initial diagnosis of celiac disease based on total villous atrophy.     

Adjunctive Thermoprotection During Percutaneous Thermal Ablation Procedures: Review of Current Techniques

CardioVascular and Interventional Radiology - Although rare, unintended thermal injury to organs surrounding the ablation zone can lead to severe complications. Over the past 15 years,...     

Percutaneous CT and Fluoroscopy-Guided Screw Fixation of Pathological Fractures in the Shoulder Girdle: Technical Report of 3 Cases

Objective

To review our initial experience with percutaneous CT and fluoroscopy-guided screw fixation of pathological shoulder-girdle fractures.

Materials and Methods

Between May 2014 and June 2015, three consecutive oncologic patients (mean age 65 years; range 57–75 years) with symptomatic pathological shoulder-girdle fractures unsuitable for surgery and radiotherapy underwent percutaneous image-guided screw fixation. Fractures occurred through metastases (n = 2) or a post-ablation cavity (n = 1). Mechanical properties of osteosynthesis were adjudged superior to stand-alone cementoplasty in each case. Cannulated screws were placed under combined CT and fluoroscopic guidance with complementary radiofrequency ablation or cementoplasty to optimise local palliation and secure screw fixation, respectively, in two cases. Follow-up was undertaken every few weeks until mortality or most recent appointment.

Results

Four pathological fractures were treated in three patients (2 acromion, 1 clavicular, 1 coracoid). Mean size of associated lesion was 2.6 cm (range 1–4.5 cm). Technical success was achieved in all cases (100 %), without complications. Good palliation and restoration of mobility were observed in two cases at 2–3 months; one case could not be followed due to early post-procedural oncologic mortality.

Conclusion

Percutaneous image-guided shoulder-girdle osteosynthesis appears technically feasible with good short-term efficacy in this complex patient subset. Further studies are warranted to confirm these promising initial results.

     

Percutaneous Image-Guided Cryoablation of Challenging Mediastinal Lesions Using Large-Volume Hydrodissection: Technical Considerations and Outcomes

Objective

This study was designed to describe the technique of percutaneous image-guided cryoablation with large-volume hydrodissection for the treatment of challenging mediastinal lesions.

Methods

Between March 2014 and June 2015, three patients (mean age 62.7 years) with four neoplastic anterior mediastinal lesions underwent five cryoablation procedures using large-volume hydrodissection. Procedures were performed under general anaesthesia using CT guidance. Lesion characteristics, hydrodissection and cryoablation data, technical success, complications, and clinical outcomes were assessed using retrospective chart review.

Results

Lesions (mean size 2.7 cm; range 2–4.3 cm) were in contact with great vessels (n = 13), trachea (n = 3), and mediastinal nerves (n = 6). Hydrodissection was performed intercostally (n = 4), suprasternally (n = 2), transsternally (n = 1), or via the sternoclavicular joint (n = 1) using 1–3 spinal needles over 13.4 (range 7–26) minutes; 450 ml of dilute contrast was injected (range 300–600 ml) and increased mean lesion-collateral structure distance from 1.9 to 7.7 mm. Vulnerable mediastinal nerves were identified in four of five procedures. Technical success was 100 %, with one immediate complication (recurrent laryngeal nerve injury). Mean follow-up period was 15 months. One lesion demonstrated residual disease on restaging PET-CT and was retreated to achieve complete ablation. At last follow-up, two patients remained disease-free, and one patient developed distant disease after 1 year without local recurrence.

Conclusions

Cryoablation using large-volume hydrodissection is a feasible technique, enabling safe and effective treatment of challenging mediastinal lesions.