Brian T. Welch

Percutaneous image-guided adrenal cryoablation: procedural considerations and technical success.

PURPOSE To assess safety, technical success, complications, and hemodynamic changes associated with the adrenal cryoablation procedure. MATERIALS AND METHODS This retrospective review was approved by the institutional review board, with waiver of informed consent, and was compliant with the Health Insurance Portability and Accountability Act. Adult patients with adrenal metastasis who were treated with adrenal cryoablation between May 2005 and October 2009 were eligible for this review. Twelve patients (undergoing 13 procedures) with single adrenal tumors were included in the analysis. For statistical analysis, hemodynamic data were averaged for the patient undergoing the procedure twice. Technical success, safety, and local control were analyzed according to standard criteria. Hemodynamic changes during the procedure were analyzed and compared with data from an unmatched cohort of patients who underwent kidney (not in the upper pole) cryoablation (Wilcoxon rank sum test). A further subanalysis of hemodynamic changes was performed on the basis of whether preprocedural α- or β-adrenergic blockade was used. RESULTS With adrenal cryoablation, local control was achieved following treatment in 11 (92%; 95% confidence interval: 65.1%, 99.6%) of 12 tumors. One patient with known adrenal insufficiency underwent conservative ablation and developed ipsilateral adrenal recurrence, which was retreated. Five patients developed hypertensive crisis during the final, active thaw phase of the cryoablation procedure, and one patient developed hypertensive crisis in the immediate postablation period. Patients undergoing adrenal cryoablation experienced a significant increase in systolic blood pressure (P = .005), pulse pressure (P = .02), and mean arterial pressure (P = .01) when compared with the cohort of kidney cryoablation patients. Adrenal cryoablation patients who were not premedicated with an α-blocker (n = 5) had a higher level of systolic blood pressure increase during the cryoablation procedure when compared with their counterparts who were premedicated (n = 7) (P = .034). CONCLUSION Adrenal cryoablation is technically feasible with a high rate of local control. Patients premedicated with the α-blocker phenoxybenzamine appear to have a reduced risk of hypertensive crisis.

A Single-Institution Experience in Image-Guided Thermal Ablation of Adrenal Gland Metastases

PURPOSE To assess safety, technical success, local control, and survival associated with percutaneous image-guided adrenal ablation. MATERIALS AND METHODS Adult patients with adrenal metastases who underwent percutaneous image-guided adrenal ablation during the years 2003-2012 were identified. There were 32 patients with 37 adrenal tumors identified. Technical success, safety, local control, and survival were analyzed according to standard criteria. RESULTS In 32 patients (25 men and 7 women; mean age, 66 y; age range, 44-88 y) with 37 adrenal tumors, 35 ablation procedures were performed. One patient with an 8.2-cm tumor underwent planned cryoablation debulking fully anticipating untreated margins owing to close proximity of the pancreas (ie, the intent was to diminish tumor burden rather than a curative intervention). Of the 36 patients treated with curative intent, technical success was achieved in 35 (97%) tumors. Follow-up imaging was performed on 34 of 37 tumors (excluding patients with intentional debulking [n = 1], technical failure [n = 1], and absence of follow-up [n = 1]). Local recurrence developed in 3 (8.8%) of 34 tumors. Local tumor control was achieved in 31 lesions at a mean of 22.7 months of follow-up. Recurrence-free survival and overall survival at 36 months were 88% and 52%, respectively, with a median survival of 34.5 months. A Common Terminology Criteria for Adverse Events version 4 grade 3 or 4 complication was observed in three (8.6%) ablation procedures. CONCLUSIONS Image-guided ablation is safe and effective for local control of metastatic adrenal tumors and provides a minimally invasive alternative to surgical resection in appropriately selected patients.

Feasibility and Oncologic Control after Percutaneous Image Guided Ablation of Metastatic Renal Cell Carcinoma

PURPOSE We assessed the safety, local control and oncologic efficacy of percutaneous ablation in the treatment of metastatic renal cell carcinoma. MATERIALS AND METHODS A retrospective review was performed of 61 patients who underwent 74 ablation procedures to treat 82 metastatic renal cell carcinoma lesions with the intent of local eradication. Technical success, local tumor control, complications and patient survival were analyzed according to standard criteria. RESULTS Four (4.9%) technical failures were observed while 2 patients were lost to followup. Time to recurrence was assessed for the subset of 76 (93%) tumors that were followed after ablation. Six (of 76, 7.9%) tumors recurred at a mean of 1.6 years after ablation (median 1.4, range 0.6 to 2.9). Thus, known overall local tumor control was achieved in 70 of 80 (87.5%) tumors. Estimated local recurrence-free survival rates (95% CI, number still at risk) at 1, 2 and 3 years after ablation were 94% (88-100, 41), 94% (88-100, 32) and 83% (70-97, 17), respectively. Estimated overall survival rates (95% CI, number still at risk) at 1, 2 and 3 years after ablation were 87% (79-97, 42), 83% (73-94, 31) and 76% (63-90, 19), respectively. CONCLUSIONS Image guided ablation of metastatic renal cell carcinoma is a relatively safe procedure with acceptable local control rates. Ablation may offer patients a minimally invasive option of local tumor eradication and warrants a role in the multimodal treatment approach for select patients.

A National Analysis of the Complications, Cost, and Mortality of Percutaneous Lung Ablation

PURPOSE To perform a national analysis of the safety and cost of percutaneous image-guided lung malignancy ablation. MATERIALS AND METHODS Using the National (Nationwide) Inpatient Sample, we evaluated complications, need for further intervention, in-hospital mortality, length of hospitalization, and hospital charges for patients undergoing inpatient percutaneous image-guided lung ablation in the United States during the period 2007-2011. Additionally, an analysis of the relationship between specific patient factors, procedural complications, and mortality was performed. RESULTS The study group consisted of 3,344 patients, including 2,072 (61.9%) patients treated for primary lung carcinomas and 1,277 (38.1%) patients treated for pulmonary metastatic disease. In-hospital mortality occurred after 43 (1.3%) ablation procedures. A Charlson comorbidity index score ≥ 4 was associated with higher mortality (odds ratio [OR], 2.84; 95% confidence interval [CI], 1.16-6.91). Pneumothorax was the most common complication (38.4%), followed by pneumonia (5.7%) and effusion (4.0%). Neither pneumothorax nor chest tube insertion was associated with higher in-hospital mortality rates (pneumothorax, OR, 1.10; 95% CI, 0.59-2.04, and chest tube insertion, OR, 1.45; 95% CI, 0.78-2.68). Surgical reintervention via thoracoscopy or thoracotomy occurred in 31 cases (0.9%). Median length of hospitalization was 1 day (interquartile range, 1-3 d), and median hospital charges were

Percutaneous Image-guided Biopsy in an Elderly Population

22,320 (interquartile range,

Percutaneous Image-Guided Biopsy of the Musculoskeletal System

13,705-

Percutaneous Ablation of Benign Bone Tumors

43,026). CONCLUSIONS Percutaneous image-guided lung ablation of primary and metastatic disease has an acceptable safety profile, and surgical reintervention is rarely required. The most frequent complications of percutaneous lung ablation were not associated with increased in-hospital mortality.

Retrospective Review of Percutaneous Image-Guided Ablation of Oligometastatic Prostate Cancer: A Single-Institution Experience

PURPOSE To evaluate the safety, accuracy, and clinical use of image-guided biopsy results in an elderly (age >/=80 years) patient population. MATERIALS AND METHODS Image-guided biopsy results of 722 elderly patients were obtained from our image-guided biopsy database over a 5-year period. This retrospective study of the data yielded 616 cases. The accuracy and complication rates for the elderly population were compared with the remaining patients in the database who were younger than 80 years of age (n= 13,012). In addition, use of biopsy results for treatment was also evaluated against a group of randomly selected younger patients who were matched for type and location of biopsy. RESULTS Image-guided biopsy in both patient groups was characterized by a high accuracy rate (95% for the elderly patients vs 96.5% for others), but the accuracy rate was significantly higher in the nonelderly group (P = .0247). Image-guided biopsy in elderly patients did not carry a greater complication rate compared with younger patients for any major complication. Use of malignant biopsy results (ie, initiating any therapy) was significantly less common in elderly patients (58% underwent therapy) than in younger age groups. In patients aged 60-70 y, 100% initiated therapy; in patients aged 70-80 y, 95% underwent therapy. CONCLUSIONS Image-guided biopsy in elderly patients is a safe and accurate procedure. There is no greater risk of complication in elderly patients. Malignant diagnoses achieved by image-guided biopsy in elderly patients resulted less frequently in the initiation of therapy for malignancy.

Subarachnoid and intraperitoneal hemorrhage secondary to segmental arterial mediolysis: A case report and review of the literature

Percutaneous image-guided biopsy plays an important role in the management of multiple pathologic conditions involving the musculoskeletal system. The vast majority of these conditions require histologic diagnosis to guide decision making concerning treatment. Percutaneous image-guided biopsy has supplanted open surgical biopsy as the primary modality for tissue diagnosis in this patient cohort. The safety, efficacy, and clinical outcome of percutaneous image-guided biopsy for a multitude of musculoskeletal conditions are well documented. Improvements in needle design and image guidance have continued to further the efficacy and safety of this diagnostic technique. Complications associated with percutaneous biopsy are minimal compared with those seen in open surgical biopsy, whereas diagnostic accuracy is comparable to that of surgical biopsy.

Evaluation of the Charges, Safety, and Mortality of Percutaneous Renal Thermal Ablation Using the Nationwide Inpatient Sample

Percutaneous image-guided ablation has become a standard of practice and one of the primary modalities for treatment of benign bone tumors. Ablation is most commonly used to treat osteoid osteomas but may also be used in the treatment of chondroblastomas, osteoblastomas, and giant cell tumors. Percutaneous image-guided ablation of benign bone tumors carries a high success rate (>90% in case series) and results in decreased morbidity, mortality, and expense compared with traditional surgical methods. The ablation technique most often applied to benign bone lesions is radiofrequency ablation. Because the ablation technique has been extensively applied to osteoid osteomas and because of the uncommon nature of other benign bone tumors, we will primarily focus this discussion on the percutaneous ablation of osteoid osteomas.