[en] PurposeRadiosurgery requires precise lesion localization. Fiducial markers enable lesion tracking, but complications from insertion may occur. The purpose of this study was to describe complications of fiducial marker insertion into pulmonary lesions.Materials and MethodsClinical and imaging records of 28 consecutive patients with 32 lung nodules or masses who underwent insertion of a total of 59 fiducial markers before radiosurgery were retrospectively reviewed.ResultsEighteen patients (67%) developed a pneumothorax, and six patients (22%) required a chest tube. The rates of pneumothorax were 82% and 40%, respectively, when 18-gauge and 19-gauge needles were used for marker insertion (P = 0.01). Increased rate of pneumothorax was also associated with targeting smaller lesions (P = 0.03) and tumors not in contact with the pleural surface (P = 0.04). A total of 11 fiducials (19%) migrated after insertion into the pleural space (10 markers) or into the airway (1 marker). Migration was associated with shorter distances from pleura to the marker deposition site (P = 0.04) and with fiducial placement outside of the target lesion (P = 0.03).ConclusionFiducial marker placement into lung lesions is associated with a high risk of pneumothorax and a risk of fiducial migration.

[en] A complication of the StarClose Vascular Closure System (Abbott, Des Plaines, IL) after a transarterial hepatic chemoembolization is described. After attempted clip deployment, the entire device became lodged in the tissues overlying the common femoral artery and could not be removed percutaneously. Successful removal of the device required surgical cutdown for removal and arterial repair. Entrapment of the StarClose vascular closure deployment system is a potentially serious complication that has been reported in the Manufacturer and User Facility Device Experience database, but has not been recognized in the literature.

No abstract available

[en] 

Introduction

The practice of positioning patients’ arms above the head during catheter-injected hepatic arterial phase cone beam CT (A-CBCT) imaging has been inherited from standard CT imaging due to image quality concerns, but interrupts workflow and extends procedure time. We sought to assess A-CBCT image quality and artifacts with arms extended above the head versus down by the side.

Methods

We performed an IRB approved retrospective evaluation of reformatted and 3D-volume rendered images from 91 consecutive A-CBCTs (43 arms up, 48 arms down) acquired during hepatic tumor arterial embolization procedures. Two interventional radiologists reviewed all A-CBCT imaging and assigned vessel visualization scores (VVS) from 1 to 5, ranging from non-diagnostic to optimal visualization. Streak artifacts across axial images were rated from 1 to 3 based on resulting image quality (none to significant). Presence of respiratory or cardiac motion during acquisition, body mass index and radiation dose area product (DAP) were also recorded and analyzed. Univariate and multivariate analyses were used to assess the impact of arm position on VVS and imaging artifacts.

Results

VVS were not significantly associated with arm position during A-CBCT imaging. One reader reported more streak artifacts across axial images in the arms down group (p = 0.005). DAP was not statistically different between the groups (23.9 Gy cm² [6.1–73.4] arms up, 26.1 Gy cm² [4.2–102.6] arms down, p = 0.54).

Conclusion

A-CBCT angiography performed with the arms above the head is not superior for clinically relevant hepatic vascular visualization compared to imaging performed with the arms by the patient’s side.

[en] Purpose: This study was designed to assess the incidence, magnitude, and impact upon retrievability of vena caval perforation by Günther Tulip and Celect conical inferior vena cava (IVC) filters on computed tomographic (CT) imaging. Methods: Günther Tulip and Celect IVC filters placed between July 2007 and May 2009 were identified from medical records. Of 272 IVC filters placed, 50 (23 Günther Tulip, 46%; 27 Celect, 54%) were retrospectively assessed on follow-up abdominal CT scans performed for reasons unrelated to the filter. Computed tomography scans were examined for evidence of filter perforation through the vena caval wall, tilt, or pericaval tissue injury. Procedure records were reviewed to determine whether IVC filter retrieval was attempted and successful. Results: Perforation of at least one filter component through the IVC was observed in 43 of 50 (86%) filters on CT scans obtained between 1 and 880 days after filter placement. All filters imaged after 71 days showed some degree of vena caval perforation, often as a progressive process. Filter tilt was seen in 20 of 50 (40%) filters, and all tilted filters also demonstrated vena caval perforation. Transjugular removal was attempted in 12 of 50 (24%) filters and was successful in 11 of 12 (92%). Conclusions: Longer indwelling times usually result in vena caval perforation by retrievable Günther Tulip and Celect IVC filters. Although infrequently reported in the literature, clinical sequelae from IVC filter components breaching the vena cava can be significant. We advocate filter retrieval as early as clinically indicated and increased attention to the appearance of IVC filters on all follow-up imaging studies.

[en] PurposeTo create and validate a planning tool for multiple-probe cryoablation, using simulations of ice ball size and shape for various ablation probe configurations, ablation times, and types of tissue ablated.Materials and MethodsIce ball size and shape was simulated using the Pennes bioheat equation. Five thousand six hundred and seventy different cryoablation procedures were simulated, using 1–6 cryoablation probes and 1–2 cm spacing between probes. The resulting ice ball was measured along three perpendicular axes and recorded in a database. Simulated ice ball sizes were compared to gel experiments (26 measurements) and clinical cryoablation cases (42 measurements). The clinical cryoablation measurements were obtained from a HIPAA-compliant retrospective review of kidney and liver cryoablation procedures between January 2015 and February 2016. Finally, we created a web-based cryoablation planning tool, which uses the cryoablation simulation database to look up the probe spacing and ablation time that produces the desired ice ball shape and dimensions.ResultsAverage absolute error between the simulated and experimentally measured ice balls was 1 mm in gel experiments and 4 mm in clinical cryoablation cases. The simulations accurately predicted the degree of synergy in multiple-probe ablations. The cryoablation simulation database covers a wide range of ice ball sizes and shapes up to 9.8 cm.ConclusionCryoablation simulations accurately predict the ice ball size in multiple-probe ablations. The cryoablation database can be used to plan ablation procedures: given the desired ice ball size and shape, it will find the number and type of probes, probe configuration and spacing, and ablation time required.

[en] 

Purpose

The goal of this study was to develop and evaluate a volumetric three-dimensional (3D) approach to improve the accuracy of ablation margin assessment following thermal ablation of hepatic tumors.

Methods

The 3D margin assessment technique was developed to generate the new 3D assessment metrics: volumes of insufficient coverage (VICs) measuring volume of tissue at risk post-ablation. VICs were computed for the tumor and tumor plus theoretical 5- and 10-mm margins. The diagnostic accuracy of the 3D assessment to predict 2-year local tumor progression (LTP) was compared to that of manual 2D assessment using retrospective analysis of a patient cohort that has previously been reported as a part of an outcome-centered study. Eighty-six consecutive patients with 108 colorectal cancer liver metastases treated with radiofrequency ablation (2002–2012) were used for evaluation. The 2-year LTP discrimination power was assessed using receiver operating characteristic area under the curve (AUC) analysis.

Results

A 3D assessment of margins was successfully completed for 93 out of 108 tumors. The minimum margin size measured using the 3D method had higher discrimination power compared with the 2D method, with an AUC value of 0.893 vs. 0.790 (p = 0.01). The new 5-mm VIC metric had the highest 2-year LTP discrimination power with an AUC value of 0.923 (p = 0.004).

Conclusions

Volumetric semi-automated 3D assessment of the ablation zone in the liver is feasible and can improve accuracy of 2-year LTP prediction following thermal ablation of hepatic tumors.

Key Points

• More accurate prediction of local tumor progression risk using volumetric 3D ablation zone assessment can help improve the efficacy of image-guided percutaneous thermal ablation of hepatic tumors.

• The accuracy of evaluation of ablation zone margins after thermal ablation of colorectal liver metastases can be improved using a volumetric 3D semi-automated assessment approach and the volume of insufficient coverage assessment metric.

• The new 5-mm volume-of-insufficient-coverage metric, indicating the volume of tumor plus 5-mm margin that remained untreated, had the highest 2-year local tumor progression discrimination power.

[en] PurposeNumerical simulations are used for treatment planning in clinical applications of irreversible electroporation (IRE) to determine ablation size and shape. To assess the reliability of simulations for treatment planning, we compared simulation results with empiric outcomes of renal IRE using computed tomography (CT) and histology in an animal model.MethodsThe ablation size and shape for six different IRE parameter sets (70–90 pulses, 2,000–2,700 V, 70–100 µs) for monopolar and bipolar electrodes was simulated using a numerical model. Employing these treatment parameters, 35 CT-guided IRE ablations were created in both kidneys of six pigs and followed up with CT immediately and after 24 h. Histopathology was analyzed from postablation day 1.ResultsAblation zones on CT measured 81 ± 18 % (day 0, p ≤ 0.05) and 115 ± 18 % (day 1, p ≤ 0.09) of the simulated size for monopolar electrodes, and 190 ± 33 % (day 0, p ≤ 0.001) and 234 ± 12 % (day 1, p ≤ 0.0001) for bipolar electrodes. Histopathology indicated smaller ablation zones than simulated (71 ± 41 %, p ≤ 0.047) and measured on CT (47 ± 16 %, p ≤ 0.005) with complete ablation of kidney parenchyma within the central zone and incomplete ablation in the periphery.ConclusionBoth numerical simulations for planning renal IRE and CT measurements may overestimate the size of ablation compared to histology, and ablation effects may be incomplete in the periphery

[en] Highlights: •The controller of a standard SCD is labeled as an “MR-unsafe”. •No commercially available “MR-safe” SCDs. •Standard SCDs can be used in iMRI by placing the device outside the MRI scanner room. •Using serial extension tubing did not cause device failure. -- Abstract: Purpose: Venous thromboembolism (VTE) is a common cause of morbidity and mortality in hospitalized and surgical patients. To reduce risk, perioperative VTE prophylaxis is recommended for cancer patients undergoing surgical or interventional procedures. Magnetic resonance imaging (MRI) is increasingly used in interventional oncology when alternative imaging modalities do not adequately delineate malignancies. Extended periods of immobilization during MRI-guided interventions necessitate an MR compatible sequential compression device (SCD) for intra-procedural mechanical VTE prophylaxis. Such devices are not commercially available. Materials and methods: A standard SCD routinely used at our institution for VTE prophylaxis during interventional procedures was used. To satisfy MR safety requirements, the SCD controller was placed in the MR control room and connected to the compression sleeves in the magnet room through the wave guide using tubing extensions. The controller pressure sensor was used to monitor adequate pressure delivery and detect ineffective low or abnormal high pressure delivery. VTE prophylaxis was provided using the above mentioned device for 38 patients undergoing MR-guided ablations. Results: There was no evidence of device failure due to loss of pressure in the extension tubing assembly. No interference with the anesthesia or interventional procedures was documented. Conclusion: Although the controller of a standard SCD is labeled as “MR-unsafe”, the SCD can be used in interventional MR settings by placing the device outside the MR scanner room. Using serial tubing extensions did not cause device failure. The described method can be used to provide perioperative mechanical VTE prophylaxis for high risk patients undergoing MR-guided procedures

[en] Primary clear cell renal cell carcinoma (ccRCC) genetic heterogeneity may lead to an underestimation of the mutational burden detected from a single site evaluation. We sought to characterize the extent of clonal branching involving key tumor suppressor mutations in primary ccRCC and determine if genetic heterogeneity could limit the mutation profiling from a single region assessment. Ex vivo core needle biopsies were obtained from three to five different regions of resected renal tumors at a single institution from 2012 to 2013. DNA was extracted and targeted sequencing was performed on five genes associated with ccRCC (von-Hippel Lindau [VHL], PBRM1, SETD2, BAP1, and KDM5C). We constructed phylogenetic trees by inferring clonal evolution based on the mutations present within each core and estimated the predictive power of detecting a mutation for each successive tumor region sampled. We obtained 47 ex vivo biopsy cores from 14 primary ccRCC's (median tumor size 4.5 cm, IQR 4.0–5.9 cm). Branching patterns of various complexities were observed in tumors with three or more mutations. A VHL mutation was detected in nine tumors (64%), each time being present ubiquitously throughout the tumor. Other genes had various degrees of regional mutational variation. Based on the mutations' prevalence we estimated that three different tumor regions should be sampled to detect mutations in PBRM1, SETD2, BAP1, and/or KDM5C with 90% certainty. The mutational burden of renal tumors varies by region sampled. Single site assessment of key tumor suppressor mutations in primary ccRCC may not adequately capture the genetic predictors of tumor behavior