Antoine Hakime

Clinical Evaluation of Spatial Accuracy of a Fusion Imaging Technique Combining Previously Acquired Computed Tomography and Real-Time Ultrasound for Imaging of Liver Metastases

PurposeThis study was designed to evaluate the spatial accuracy of matching volumetric computed tomography (CT) data of hepatic metastases with real-time ultrasound (US) using a fusion imaging system (VNav) according to different clinical settings.MethodsTwenty-four patients with one hepatic tumor identified on enhanced CT and US were prospectively enrolled. A set of three landmarks markers was chosen on CT and US for image registration. US and CT images were then superimposed using the fusion imaging display mode. The difference in spatial location between the tumor visible on the CT and the US on the overlay images (reviewer #1, comment #2) was measured in the lateral, anterior–posterior, and vertical axis. The maximum difference (Dmax) was evaluated for different predictive factors.CT performed 1–30xa0days before registration versus immediately before.Use of general anesthesia for CT and US versus no anesthesia.Anatomic landmarks versus landmarks that include at least one nonanatomic structure, such as a cyst or a calcificationResultsOverall, Dmax was 11.53xa0±xa08.38xa0mm. Dmax was 6.55xa0±xa07.31xa0mm with CT performed immediately before VNav versus 17.4xa0±xa05.18 with CT performed 1–30xa0days before (pxa0<xa00.0001). Dmax was 7.05xa0±xa06.95 under general anesthesia and 16.81xa0±xa06.77 without anesthesia (pxa0<xa00.0015). Landmarks including at least one nonanatomic structure increase Dmax of 5.2xa0mm (pxa0<xa00.0001). The lowest Dmax (1.9xa0±xa01.4xa0mm) was obtained when CT and VNav were performed under general anesthesia, one immediately after the other.ConclusionsVNav is accurate when adequate clinical setup is carefully selected. Only under these conditions (reviewer #2), liver tumors not identified on US can be accurately targeted for biopsy or radiofrequency ablation using fusion imaging.

Percutaneous Femoral Implantation of an Arterial Port Catheter for Intraarterial Chemotherapy: Feasibility and Predictive Factors of Long-term Functionality

PURPOSEnTo evaluate the feasibility, functionality, and dysfunctions of an arterial port catheter implanted via the femoral artery.nnnMATERIALS AND METHODSnFrom November 2001 to May 2008, 93 consecutive patients (mean age 57 years old) with unresectable hepatic colorectal metastases were referred for intraarterial chemotherapy. The arterial port catheters were percutaneously implanted via the femoral artery. The catheter tips were placed as free-floating in the common hepatic artery (technique 1), fixed in the gastroduodenal artery (technique 2), or inserted in a segmental hepatic artery (technique 3). Embolization of the right gastric artery was always attempted.nnnRESULTSnThe technical success rate of the femoral approach was 94% (n = 88 of 93). Intraarterial chemotherapy (average 7.3 courses) was administered to 84 patients. Migration and occlusion of the catheters occurred in 12% (n = 10 of 84) and 11% (n = 9 of 84) of patients, and extrahepatic perfusion occurred in 30% (n = 25 of 84) of patients. Catheter migration occurred significantly more frequently with technique 1 (50%; n = 3 of 6) than with technique 2 (11%; n = 7 of 64; P = .03) or technique 3 (0%; n = 0 of 14; P = .02). Occurrence of gastroduodenal ulcerations was significantly lower (P = .01) when embolization of the right gastric artery was performed (8%; n = 4 of 48) than when it was not (28%; n = 11 of 36). The success rate of embolization of the right gastric artery significantly improved (P = .006) from the first half of patients treated to the second half, resulting in a significant (P = .02) decrease in the occurrence of ulcerations from 28% (n = 12 of 42) in the first half of patients treated to 7% (n = 3 of 42) in the second half.nnnCONCLUSIONSnPercutaneous femoral placement of an arterial port catheter is highly feasible. Right gastric artery embolization and use of techniques 2 and 3 are good predictive factors for long-term functionality.

Electromagnetic-Tracked Biopsy under Ultrasound Guidance: Preliminary Results

PurposeThis study was designed to evaluate the accuracy and safety of electromagnetic needle tracking for sonographically guided percutaneous liver biopsies.MethodsWe performed 23 consecutive ultrasound-guided liver biopsies for liver nodules with an electromagnetic tracking of the needle. A sensor placed at the tip of a sterile stylet (18G) inserted in a coaxial guiding trocar (16G) used for biopsy was localized in real time relative to the ultrasound imaging plane, thanks to an electromagnetic transmitter and two sensors on the ultrasound probe. This allows for electronic display of the needle tip location and the future needle path overlaid on the real-time ultrasound image. Distance between needle tip position and its electronic display, number of needle punctures, number of needle pull backs for redirection, technical success (needle positioned in the target), diagnostic success (correct histopathology result), procedure time, and complication were evaluated according to lesion sizes, depth and location, operator experience, and “in-plane” or “out-of-plane” needle approach.ResultsElectronic display was always within 2xa0mm from the real position of the needle tip. The technical success rate was 100%. A single needle puncture without repuncture was used in all patients. Pull backs were necessary in six patients (26%) to obtain correct needle placement. The overall diagnostic success rate was 91%. The overall true-positive, true-negative, false-negative, and failure rates of the biopsy were 100% (19/19) 100% (2/2), 0% (0/23), and 9% (2/23). The median total procedure time from the skin puncture to the needle in the target was 30 sec (from 5–60 s). Lesion depth and localizations, operator experience, in-plane or out-of-plane approach did not affect significantly the technical, diagnostic success, or procedure time. Even when the tumor size decreased, the procedure time did not increase.ConclusionsElectromagnetic-tracked biopsy is accurate to determine needle tip position and allows fast and accurate needle placement in targeted liver nodules.

Percutaneous Bone Biopsies: Comparison between Flat-Panel Cone-Beam CT and CT-Scan Guidance

PurposeThis study was designed to compare the accuracy of targeting and the radiation dose of bone biopsies performed either under fluoroscopic guidance using a cone-beam CT with real-time 3D image fusion software (FP-CBCT-guidance) or under conventional computed tomography guidance (CT-guidance).MethodsSixty-eight consecutive patientsxa0with a bone lesion were prospectively included. The bone biopsiesxa0werexa0scheduled under FP-CBCT-guidance or under CT-guidance according to operating room availability. Thirty-four patients underwent a bone biopsy under FP-CBCT and 34 under CT-guidance. We prospectively compared the two guidance modalities for their technical success, accuracy, puncture time, and pathological success rate. Patient and physician radiation doses also were compared.ResultsAll biopsies were technically successful, with both guidance modalities. Accuracy was significantly better using FP-CBCT-guidance (3 and 5xa0mm respectively: pxa0=xa00.003). There was no significant difference in puncture time (32 and 31xa0min respectively, pxa0=xa00.51) nor in pathological results (88 and 88xa0% of pathological success respectively, pxa0=xa01). Patient radiation doses were significantly lower with FP-CBCT (45 vs. 136xa0mSv, pxa0<xa00.0001). The percentage of operators who received a dose higher than 0.001xa0mSv (dosimeter detection dose threshold) was lower with FP-CBCT than CT-guidance (27 vs. 59xa0%, pxa0=xa00.01).ConclusionsFP-CBCT-guidance for bone biopsy is accurate and reduces patient and operator radiation doses compared with CT-guidance.

IRM et maladies pancréatiques

Resume L’IRM du pancreas a connu beaucoup de changements notamment grâce a sa capacite a visualiser de facon optimale les canaux pancreatiques et les modifications de signal du parenchyme. La cholangio-pancreato-IRM permet la reconnaissance de variantes anatomiques comme le pancreas divisum. Bien que le scanner soit la methode de reference dans la pancreatite aigue et pour la detection des calcifications pancreatiques au cours de la pancreatite chronique, l’IRM du pancreas et l’IRM avec injection de secretine sont utiles pour la recherche de la cause de la pancreatite, et l’evaluation des complications telles que les pseudokystes et la rupture canalaire. Le role de l’IRM est toujours debattu dans les tumeurs pancreatiques en dehors des lesions kystiques ou l’IRM apporte des informations capitales en vue de la caracterisation en etudiant le nombre de kystes, le contenu des lesions et le caractere communiquant ou non avec les canaux pancreatiques. L’IRM est aussi interessante pour d’autres pathologies pancreatiques comme la pancreatite autoimmune (diagnostic positif, cholangite associee ?) ou la pancreatite de la jante (kystes d’une dystrophie kystique sur pancreas aberrant ?).

Percutaneous osteosynthesis in the pelvis in cancer patients.

AbstractPurposeScrew fixation (osteosynthesis) can be performed percutaneously by interventional radiologists. We report our experience in cancer patients.Material/methodsWe retrospectively reviewed all cases of percutaneous osteosynthesis (PO) of the pelvic ring and proximal femur performed in our hospital. PO were performed for fracture palliation or for osteolytic metastases consolidation. Screws were inserted under CT- or cone-beam CT- guidance and general anaesthesia. Patients were followed-up with pelvic-CT and medical consultation at 1xa0month, then every 3xa0months. For fractures, the goal was pain palliation and for osteolytic metastases, pathologic fracture prevention.ResultsBetween February 2010 and August 2014, 64 cancer patients were treated with PO. Twenty-one patients had PO alone for 33 painful fractures (13 bone-insufficiency, 20 pathologic fractures). The pain was significantly improved at 1xa0month (VAS scoreu2009=u200920/100 vs. 80/100). In addition, 43 cancer patients were preventively consolidated using PO plus cementoplasty for 45 impending pathologic fractures (10 iliac crests, 35 proximal femurs). For the iliac crests, no fracture occurred (median-FUu2009=u200975xa0days). For the proximal femurs, 2 pathological fractures occurred (fracture rateu2009=u20095.7xa0%, median-FUu2009=u2009205xa0days).ConclusionPO is a new tool in the therapeutic arsenal of interventional radiologists for bone pain management.Key Points• Screw fixation (osteosynthesis) can be performed percutaneously by interventional radiologists.n • CT- or CBCT-guidance results in high technical success rates for screw placement.n • This minimally invasive technique avoids extensive surgical exposure in bone cancer patients.n • Osteosynthesis provides pain relief for bone-insufficiency fractures and for pathologic fractures.n • Osteosynthesis plus cementoplasty provide prophylactic consolidation of impending pathological fractures.

A Role for Adjuvant RFA in Managing Hepatic Metastases from Gastrointestinal Stromal Tumors (GIST) After Treatment with Targeted Systemic Therapy Using Kinase Inhibitors

PurposeThis study was designed to assess the role of radiofrequency ablation (RFA) in the multimodality management of gastrointestinal stromal tumors (GIST) in patients undergoing targeted tyrosine kinase inhibitor therapy (TKI) for liver metastases.MethodsOutcomes of 17 patients who underwent liver RFA for 27 metastatic GIST after TKI therapy, from January 2004 to March 2012, were retrospectively analyzed. Mean maximum tumor diameter was 2.5xa0±xa01xa0cm (range 0.9–4.5xa0cm). In seven patients (group A), RFA of all residual tumors was performed, with curative intent, and TKI therapy was discontinued. In five patients (group B), RFA of all residual tumors was performed upon achieving the best morphological response with TKI therapy, which was maintained after RFA. In another five patients (group C), RFA was performed on individual liver metastases which were progressive under TKI therapy.ResultsAll 27 targeted tumors were completely ablated, without local recurrence during the mean follow-up period of 49xa0months. No major complications occurred. Two minor complications were reported (11xa0%). Only two patients (both in group C) died at 20 and 48xa0months. Two-year progression-free survival (PFS) after RFA was 29xa0% in group A, 75xa0% in group B, and 20xa0% in group C.ConclusionsRFA in patients, previously treated with TKI, is feasible and safe. Our data suggest that RFA is a useful therapeutic option in patients with metastatic GIST and should be performed at the time of best clinical response with patient maintained under TKI after the procedure.

Fatty Hepatocellular Carcinoma: Radiofrequency Ablation—Imaging Findings

PURPOSEnTo describe the imaging features during follow-up after radiofrequency (RF) ablation of fat-containing hepatocellular carcinoma (HCC).nnnMATERIALS AND METHODSnInstitutional review board approval was obtained; informed consent was waived. A retrospective search in an electronic radiologic archive was performed for a 40-month period between February 2004 and May 2007 to identify patients who had undergone RF ablation of fat-containing HCCs. The presence of intratumoral fat was determined at imaging (magnetic resonance or computed tomography) prior to the RF procedure; eight fat-containing HCCs, which had a mean size of 25 mm (range, 20-30 mm), were found. Images during follow-up were reviewed and compared with images prior to RF ablation to determine changes in fat content, complete or partial ablation, and local tumor progression. Tumor response was on the basis of assessment of lesion characteristics and enhancement for a follow-up of at least 6 months.nnnRESULTSnPersistent fat content was found at imaging in all ablation zones. Six patients were considered to have completely ablated tumors (mean follow-up, 16 months; range, 6-29 months), and two patients had local progression (mean follow-up, 18 months; range, 14-22 months). In the ablation zone of completely ablated tumors, the fat content progressively decreased (n = 4) or was unchanged during follow-up (n = 2). In the two tumors with local progression, the fat portion enlarged (n = 1) or did not change after ablation (n = 1).nnnCONCLUSIONnPersistence of fat in the ablation zone during imaging follow-up after RF ablation of fat-containing HCCs does not necessarily indicate treatment failure. Changes in fat content of the ablation zone during follow-up (increase or decrease in size) could be used as additional criteria to determine success or failure of RF ablation in fat-containing HCC.

Percutaneous Ultrasound-Guided Carpal Tunnel Release: Study Upon Clinical Efficacy and Safety

ObjectivesTo evaluate the feasibility and 6xa0months clinical result of sectioning of the transverse carpal ligament (TCL) and median nerve decompression after ultra-minimally invasive, ultrasound-guided percutaneous carpal tunnel release (PCTR) surgery.MethodsConsecutive patients with carpal tunnel syndrome were enrolled in this descriptive, open-label study. The procedure was performed in the interventional radiology room. Magnetic resonance imaging was performed at baseline and 1xa0month. The Boston Carpal Tunnel Questionnaire was administered at baseline, 1, and 6xa0months.Results129 patients were enrolled. Significant decreases in mean symptom severity scores (3.3xa0±xa00.7 at baseline, 1.7xa0±xa00.4 at Month 1, 1.3xa0±xa00.3 at Month 6) and mean functional status scores (2.6xa0±xa01.1 at baseline, 1.6xa0±xa00.4 at Month 1, 1.3xa0±xa00.5 at Month 6) were noted. Magnetic resonance imaging showed a complete section of all TCL and nerve decompression in 100% of patients. No complications were identified.ConclusionsUltrasound-guided PCTR was used successfully to section the TCL, decompress the median nerve, and reduce self-reported symptoms.

Factors associated with success of image-guided tumour biopsies: Results from a prospective molecular triage study (MOSCATO-01)

INTRODUCTIONnMOSCATO-01 is a molecular triage trial based on on-purpose tumour biopsies to perform molecular portraits. We aimed at identifying factors associated with high tumour cellularity.nnnMATERIAL AND METHODSnTumour cellularity (percentage of tumour cells in samples defined at pathology) was evaluated according to patient characteristics, target lesion characteristics, operators experience and biopsy approach.nnnRESULTSnAmong 460 patients enrolled between November, 2011 and March, 2014, 334 patients (73%) had an image-guided needle biopsy of the primary tumour (Nxa0=xa038) or a metastatic lesion (Nxa0=xa0296). Biopsies were performed on liver (Nxa0=xa0127), lung (Nxa0=xa072), lymph nodes (Nxa0=xa071), bone (Nxa0=xa011), or another tumour site (Nxa0=xa053). Eighteen patients (5%) experienced a complication: pneumothorax in 10 patients treated medically, and haemorrhage in 8, requiring embolisation in 3 cases. Median tumour cellularity was 50% (interquartile range, 30-70%). The molecular analysis was successful in 291/334 cases (87%). On-going chemotherapy, tumour origin (primary versus metastatic), lesion size, tumour growth rate, presence of necrosis on imaging, standardised uptake value, and needle size were not statistically associated with cellularity. Compared to liver or lung biopsies, cellularity was significantly lower in bone and higher in other sites (Pxa0<xa00.0001). Cellularity significantly increased with the number of collected samples (Pxa0<xa00.0001) and was higher in contrast-enhanced ultrasound-guided biopsies (Pxa0<xa00.02). In paired samples, cellularity in central samples was lower than in peripheral samples in 85, equal in 68 and higher in 89 of the cases.nnnCONCLUSIONnImage-guided biopsy is feasible and safe in cancer patients for molecular screening. Imaging modality, multiple sampling of the lesion, and the organ chosen for biopsy were associated with higher tumour cellularity.