Multiple-electrode radiofrequency ablations using Octopus(R)electrodes in an in vivo porcine liver model

Objectives

The objective of this study was to determine the in vivo efficacy of radiofrequency ablation (RFA) in porcine liver using Octopus® electrodes for creating a large coagulation compared with RFA using clustered electrodes.

Methods

A total of 39 coagulations were created using a 200-W generator and clustered electrodes or Octopus electrodes during laparotomy in 19 pigs. Radiofrequency was applied to the livers using four protocols: (1) Group A-1, monopolar mode using a clustered electrode (n=11); (2) Group A-2, monopolar mode using an Octopus electrode (n=11); (3) Group B-1, consecutive monopolar mode using three, clustered electrodes (n=8); and (4) Group B-2, switching monopolar mode using two Octopus electrodes (n=9). The energy efficiency, shape, diameters (D) and volume (V) of the coagulation volume were compared in each of the two groups.

Results

The mean maximum D and V of the coagulations in Group A-2 (4.7 cm and 33.1 cm³, respectively) were significantly larger than those in Group A-1 (4.1 cm and 20.3 cm³, respectively) (p<0.05). Furthermore, the mean minimum D, maximum D and V of the coagulations in Group B-2 were significantly larger than those in Group B-1, i.e. 5.3 vs 4.0 cm, 6.6 vs 4.9 cm and 66.9 vs 30.2 cm³, respectively (p<0.05). The energy efficiencies were also significantly higher in Groups A-2 and B-2 than in Groups A-1 and B-1 (p<0.05).

Conclusion

The Octopus electrodes were more efficient for creating a large ablation zone than clustered electrodes, and the efficacy of RFA with Octopus electrodes can be amplified in the switching monopolar mode.In recent years, image-guided percutaneous tumour ablation using radiofrequency (RF) energy has become increasingly popular and has gained wide acceptance as a valuable, minimally invasive treatment for primary and secondary liver malignancies [1]. Compared with conventional surgery, RF ablation (RFA) has many advantages in terms of reduced complications, morbidity and mortality as well as its cost-effectiveness. However, a major obstacle preventing the widespread use of RFA is its inability to reliably create adequate volumes of complete tumour destruction with sufficient safety margins, thus causing an increasing rate of marginal recurrence in large tumours due to the incomplete RFA. Most clinically available electrodes, including internally cooled electrodes, clustered electrodes, multitined expandable needle electrodes and perfusion electrodes, can induce coagulation necrosis in the range of 3–4 cm in diameter after a single ablation session [2,3]. Therefore, to treat liver tumours >3 cm in diameter, multiple overlapping ablations are often required to cover the entire tumour volume as well as the peripheral ablation margins [4,5]. However, in clinical practice, there is considerable difficulty repositioning the probe under ultrasound guidance during overlapping ablations as numerous microbubbles form in the heated tissue during RFA and may thus interfere with finding the electrode tip and the untreated portions of the target tumour on ultrasound [6].In order to avoid problems related to multiple overlapping ablations, including technical difficulties and a long procedure time, several approaches have been used to treat medium and large liver tumours. These include the use of cluster electrodes [7], multitined electrodes with saline infusion (RITA Medical Systems, Mountain View, CA) [2] and multiple electrodes in the switching monopolar mode or multipolar mode [8-11]. Although several previous studies demonstrated that the use clustered electrodes or multiple electrodes in the switching or multipolar modes could create larger coagulations [2,3,6,8-14], they also presented several potential unsolved problems. The clustered electrode problems include: (1) convergence of the three individual needles <5 mm; (2) limited access to the target tumour owing to narrow intercostal spaces; and (3) displacement of the liver due to its resistance to the electrode. Although RFA using multiple electrodes can successfully treat large liver tumours, it is still not widely used in clinical practice, primarily owing to its high cost and the complexity of using multiple electrodes.Recently, in order to improve the efficiency of clustered electrodes in creating a large ablation zone and to diminish any potential problems, we developed a separable clustered electrode (Octopus®; Taewoong Medical Co., Ltd, Goyang, Republic of Korea) with a specialised handle that can be incorporated into a larger handle in a single unit (Figure 1). Our electrode can be placed as a single electrode with variable interelectrode distances, according to the shape and size of the target tumour, or in a similar way to the clustered electrodes that are also composed of three electrodes as a single body at a fixed 5-mm interelectrode distance. Therefore, prior to their clinical application, we attempted to prove the in vivo efficacy of RFA using the Octopus electrodes to create a large area of coagulation necrosis in either the conventional or switching monopolar mode compared with RFA using a clustered electrode in porcine liver.Open in a separate windowFigure 1(a,b) Photographs of the Octopus® electrodes (Taewoong Medical Co., Ltd, Goyang, Republic of Korea), all of which have three individual needles. (c) Adaptor for the Octopus electrodes which connects the three cables to one port. (d) An illustration, which shows details of the connection between the needles and radiofrequency (RF) ablution system in a three Octopus electrodes system.     

Enhancement patterns of hepatocellular carcinomas on multiphasicmultidetector row CT: comparison with pathological differentiation

Objective The objective of this study was to determine the incidence of typical and atypical enhancement patterns of hepatocellular carcinomas (HCCs) on multiphasic multidetector row CT (MDCT) and to correlate the enhancement patterns and morphological image findings of HCC with the degree of tumour differentiation. Methods MDCT images of 217 patients with 243 surgically proven HCCs were evaluated through consensus reading by two radiologists. Our MDCT protocol was composed of precontrast, arterial, portal and delayed phases. The reviewers analysed the CT images for degree of attenuation; relative timing of washout; presence of dysmorphic intratumoral vessels, aneurysms and necrosis; tumour size; tumour margin; presence of pseudocapsule; intratumoral heterogeneity; and determined enhancement pattern. The imaging features were correlated with tumour differentiation using Fisher's exact test or the χ(2) test. Results Among 243 HCCs, 137 (56.4%) showed the typical enhancement pattern of HCC, which is arterial enhancement and washout on portal or equilibrium phase images. In the arterial phase, 190 of 243 (78.2%) HCCs showed hypervascularity, with approximately three quarters of poorly differentiated (PD) (34 of 45, 75.6%) and moderately differentiated (MD) HCCs (92 of 123, 74.8%) showing washout during the portal or delayed phases, vs only 50% of well-differentiated (WD) HCCs (11 of 22; p<0.048). The presence of intratumoral vessels and aneurysms, tumour necrosis, attenuation of precontrast, the relative timing of washout, intratumoral attenuation heterogeneity, tumour margin and tumour size were correlated with the pathological differentiation of HCCs (p<0.05). Conclusion A typical enhancement of HCCs on MDCT was not unusual (43.6%) and WD and PD HCCs account for most of the atypical enhancement patterns. Early washout favoured MD and PD HCCs rather than WD HCCs, whereas in our study the presence of intratumoral aneurysm was a highly specific finding for PD HCC.     

A cohort mortality and cancer incidence survey of recent entrants (1982-91) to the UK rubber industry: findings for 1983-2004

AIM: To monitor the occurrence of cancer in a recently defined cohort of UK rubber workers. METHODS: A cohort of 8651 male and female workers from 41 UK rubber factories has been enumerated. All employees had a minimum of 12 months employment and were first employed at one of the participating factories in the period 1982-91. Mortality and cancer incidence data for the period 1983-2004 were compared with expected values based on appropriate national rates. RESULTS: Mortality from lung cancer was close to expectation for males [observed 22, standardized mortality ratio (SMR) 93] and females (observed 2, SMR 70). Mortality from stomach cancer was also unexceptional in males (observed 4, SMR 86) and females (observed 0, SMR 0). Although based on small numbers, significantly elevated mortality was shown for multiple myeloma in males (observed 5, SMR 385) and females (observed 2, SMR 952). All seven of these latter deaths occurred in workers from the general rubber goods (GRG) sector. CONCLUSIONS: The findings should be treated with caution as they relate to a relatively early period of follow-up. Nevertheless, they hold out the prospect that the elevated SMRs for stomach and lung cancers reported for historical cohorts of UK rubber workers will not be present in more recent cohorts. The elevated occurrence of multiple myeloma may represent no more than a chance finding. Alternatively, these findings may reflect the presence of an unrecognized occupational cancer hazard in parts of the GRG sector of the UK rubber industry.     

Cerebellar ataxia, peripheral neuropathy, "gluten sensitivity" and anti-neuronal autoantibodies

"Gluten sensitive" neurological syndromes (ataxia, peripheral neuropathy, and other conditions) have been hypothesised in patients with various idiopathic neuropathologies, detectable anti-gliadin antibodies and HLA-DQ2 or DQ7. Further investigation of these cases has suggested a high incidence of anti-neuronal antibodies (anti-Purkinje, anti- neuronal nuclear, anti-GAD). This study investigates this contentious area. Over a two-year period, from a local UK population base of two million, seeing over 5000 general neurology referrals per year, we collected 20 cases with idiopathic ataxia, and 32 with idiopathic peripheral neuropathy, and referred them all for blinded antibody testing. 30 adult healthy blood donors, and 7 cases of hereditary ataxia were used as control subjects. Anti-gliadin antibodies (IgG and or IgA) were found in 40% of cases with idiopathic ataxia, 34% with idiopathic peripheral neuropathy, 17% healthy blood donors and 43% with hereditary ataxia. None was positive for antiPurkinje cell or anti-neuronal nuclear antibodies. Only two patients with idiopathic ataxia were positive for antiGAD antibodies (one also being anti-gliadin positive). We were unable to confirm the findings of other groups. First, cases of so-called "gluten sensitive" neurological syndromes were extremely rare in our centre. Second, our idiopathic cases, whether they be gliadin antibody seropositive or not (i.e. "gluten sensitive" or not) were rarely neuronal autoantibody positive.     

Endoscopic Management of Vesicoureteral Reflux and Long-term Follow-up

Objectives

To report our experience with endoscopic management of vesicoureteral reflux (VUR) by injection of a tissue bulking substance–Dextranomer/ hyaluronic acid copolymer at vesicoureteric junction.

Design

Retrospective analyses of case records.

Setting

Pediatric Surgery department in a tertiary care government Institute.

Participants

500 children (767 renal units) consecutively referred to the out-patient department with vesicoureteral reflux noted on micturating cysto-urethrogram (MCU) over a period of 13 years (2004-2016).

Intervention

Preoperative VUR grading and renal scars on radionuclide scans were documented. Dextranomer hyaluronic acid copolymer was injected through a cystoscope at the vesicoureteral junction as a day care procedure under short anesthesia. Patients were followed (average duration 27.3 mo) with clinical assessment, periodic urine cultures and renal scans.

Main outcome measure

Cessation of VUR and symptomatic relief / clinical success postoperatively at 3 months.

Results

Complete symptomatic relief was obtained in 482 (96.4%) patients. In 681 units where MCU was available, 614 (90%) units showed resolution of VUR.

Conclusion

Endoscopic injection of tissue bulking substances at vesicoureteric junction to stop VUR seems to be an effective intervention

     

The α7 nicotinic ACh receptor agonist compound B and positive allosteric modulator PNU-120596 both alleviate inflammatory hyperalgesia and cytokine release in the rat

BACKGROUND AND PURPOSE

Agonists selective for the α7 nicotinic acetylcholine (nACh) receptor produce anti-hyperalgesic effects in rodent models of inflammatory pain, via direct actions on spinal pain circuits and possibly via attenuated release of peripheral pro-inflammatory mediators. Increasingly, allosteric modulation of ligand-gated receptors is recognized as a potential strategy to obtain desired efficacy in the absence of the putative adverse effects associated with agonist activation.

EXPERIMENTAL APPROACH

We compared the anti-hyperalgesic and anti-inflammatory effects of the α7 nACh receptor agonist compound B with the positive allosteric modulator (PAM) PNU-120596 and the standard non-steroidal anti-inflammatory drug (NSAID), diclofenac, in rats with hind paw inflammation induced by either formalin, carrageenan or complete Freund''s adjuvant (CFA).

KEY RESULTS

When administered before carrageenan, both diclofenac (30 mg·kg⁻¹) and PNU-120596 (30 mg·kg⁻¹) significantly reduced mechanical hyperalgesia and weight-bearing deficits for up to 4 h. Compound B (30 mg·kg⁻¹) also attenuated both measures of pain-like behaviour, albeit less robustly. Whereas compound B and PNU-120596 attenuated the carrageenan-induced increase in levels of TNF-α and IL-6 within the hind paw oedema, diclofenac only attenuated IL-6 levels. Established mechanical hyperalgesia induced by carrageenan or CFA was also partially reversed by compound B and PNU-120596. However, diclofenac was considerably more efficacious. Formalin-induced nocifensive behaviours were only reversed by compound B, albeit at doses which disrupted motor performance.

CONCLUSIONS AND IMPLICATIONS

α7 nACh receptor PAMs could prove to be useful in the treatment of inflammatory pain conditions, which respond poorly to NSAIDs or in situations where NSAIDs are contra-indicated.