C. Fugazzola

Percutaneous imaging-guided ablation therapies in the treatment of symptomatic bone metastases: preliminary experience

PurposeThe treatment of pain in bone metastases is currently multidisciplinary. Among the various therapies, local radiotherapy is the gold standard for pain palliation from single metastasis, even though the maximum benefit is obtained between 12 and 20 weeks from initiation. In carefully selected patients, several ablation therapies achieve this objective in 4 weeks. The purpose of this study was to assess the technical success, effectiveness and possible complications of percutaneous ablation therapies in patients with symptomatic bone metastases.Materials and methodsFrom November 2003 to May 2008, ten ablation treatments were performed in ten patients with acute pain from metastatic bone lesions. Patient selection and choice of the most appropriate ablation treatment was made based on lesion characteristics. Three patients were treated with radiofrequency, one with plasma-mediated radiofrequency, two with plasma-mediated radiofrequency and cementoplasty, three with radiofrequency and cementoplasty and one with microwave.ResultsAssessments were based not only on imaging but also on the visual analogue scale (VAS) score for determining pain and on changes in morphine-equivalent doses. In both cases, 3-month follow-up showed a statistically significant reduction of pain. In no case did local complications occur either during or after treatment. Only one patient treated with radiofrequency (1/9, 11%) developed low-grade fever and general malaise during the 6 days following the procedure, compatible with a post-radiofrequency syndrome, which was treated with acetaminophen (paracetamol) only and resolved on day 7.ConclusionsPercutaneous ablation therapies represent a safe and valuable alternative for treating localised pain from single bone metastasis, providing rapid (4-week) relief of symptoms and a significant reduction in morphine doses. This contributes to improving the quality of life of patients with metastatic disease.RiassuntoObiettiviIl trattamento del dolore nelle metastasi ossee è attualmente multidisciplinare. Tra le varie terapie, la radioterapia locale è il gold-standard nella palliazione del dolore da metastasi singola, anche se il massimo beneficio si ottiene tra le 12 e le 20 settimane dall’inizio della terapia. In pazienti accuratamente selezionati, varie terapie ablative raggiungono quest’obiettivo in 4 settimane. Scopo di questo lavoro è valutare il successo tecnico, l’efficacia e le eventuali complicanze delle terapie ablative percutanee in pazienti affetti da metastasi ossee sintomatiche.Materiali e metodiDa novembre 2003 a maggio 2008 sono stati effettuati 10 trattamenti in 10 pazienti con dolore acuto da lesioni metastatiche ossee. La selezione dei pazienti e la scelta del trattamento ablativo più idoneo è stata fatta sulla base delle caratteristiche della lesione. Tre pazienti sono stati trattati con radiofrequenza, 1 con radiofrequenza plasma-mediata, 2 con radiofrequenza plasma mediata e cementoplastica, 3 con radiofrequenza e cementoplastica, 1 con microonde.RisultatiLa valutazione è stata effettuata non solo con imaging, ma anche con una VAS score (visual analoge scale) per la determinazione del dolore e con la variazione delle dose equivalenti di morfina. In entrambi i casi la riduzione è stata statisticamente significativa. In nessun caso si sono verificate complicanze locali sia durante che dopo il trattamento. Solamente in un paziente trattato con radiofrequenza (1/9, 11%) abbiamo riscontrato nei 6 giorni successivi al trattamento insorgenza di febbricola e malessere generale compatibile con la “sindrome post-radiofrequenza”, risoltasi poi al settimo giorno e trattata solo con acetaminofene (paracetamolo).ConclusioniLe tecniche ablative percutanee rappresentano una sicura e valida alternativa al trattamento del dolore localizzato da metastasi ossee singole, apportando in breve tempo (4 settimane) un miglioramento della sintomatologia e una sensibile riduzione delle dosi di morfina. Ciò concorre a migliorare la qualità della vita in pazienti affetti da malattia metastatica.

Percutaneous Treatment of Traumatic Upper-extremity Arterial Injuries: A Single-center Experience

PURPOSEnTo assess the feasibility and effectiveness of emergency percutaneous treatment of traumatic injuries of upper-extremity arteries.nnnMATERIALS AND METHODSnBetween January 2000 and December 2007, 11 patients (mean age, 49.9 years) with traumatic injuries of upper-extremity arteries were observed: three had pseudoaneurysms, four had dissections, three had transections, and one had mural hematoma. Lesions involved the axillary (n = 6), subclavian (n = 3), or brachial artery (n = 2). Pseudoaneurysms and transections were treated with stent grafts, (n = 6) and dissections and mural hematomas were treated with bare stents (n = 2) or angioplasty (n = 3). Follow-up (mean, 45.1 months; range, 12-84 months) was performed with color Doppler ultrasonography at 1, 3, 6, and 12 months and then, yearly.nnnRESULTSnImmediate technical success was obtained in all cases. No major complications occurred; there was one asymptomatic occlusion of the interosseous artery and one case of incomplete thrombosis of the radial artery (with recanalization after 1 month with systemic medical therapy). During a mean follow-up of 45.1 months, one stent-graft occlusion occurred, which was treated with intraarterial pharmacologic thrombolysis (urokinase 60,000 IU/h for 12 hours). Overall primary clinical success rate was 95.2% and secondary clinical success rate was 100%.nnnCONCLUSIONSnPercutaneous treatment is a feasible and safe tool for injuries of upper-extremity arteries because it can provide a fast and definitive termination of bleeding or a resolution of acute ischemia. This approach, with its low invasiveness, can be proposed as first-line treatment in patients with traumatic lesions of upper-extremity arteries.

Treatment of secondary hyperparathyroidism with ultrasonographically guided percutaneous radiofrequency thermoablation.

We present a case of a 63-year-old woman with a recurrent secondary hyperparathyroidism hyperplasia with absolute contraindication for surgery, treated in 2 sessions with percutaneous ultrasonographically guided radiofrequency tissue ablation. The complete pathologic tissue ablation was confirmed by contrast-enhanced ultrasonography performed before and after the treatment and by clinical and laboratory follow-up. Furthermore in work progress, the percutaneous ultrasonographically guided radiofrequency tissue ablation can be considered a feasible and effective nonsurgical alternative treatment for symptomatic secondary hyperparathyroidism in high-risk patients.

Ultrasound-Guided Radiofrequency Thermal Ablation of Uterine Fibroids: Medium-Term Follow-Up

Previous studies have shown that radiofrequency thermal ablation (RFA) of uterine fibroids through a percutaneous ultrasound (US)-guided procedure is an effective and safe minimally invasive treatment, with encouraging short-term results. The aim of this study was to assess the results in terms of volume reduction and clinical symptoms improvement in the midterm follow-up of fibroids with a diameter of up to 8xa0cm. Eleven premenopausal females affected by symptomatic fibroids underwent percutaneous US-guided RFA. Symptom severity and reduction in volume were evaluated at 1, 3, 6, 9, and 12xa0months. The mean symptom score (SSS) before the procedure was 50.30 (range 31.8–67.30), and the average quality of life (QOL) score value was 62 (range 37.20–86.00). The mean basal diameter was 5.5xa0cm (range 4.4–8) and the mean volume was 101.5xa0cm3 (range 44.58–278xa0cm3). The mean follow-up was 9xa0months (range 3–12xa0months). The mean SSS value at the end of the follow-up was 13.38 (range 0–67.1) and the QOL 90.4 (range 43.8–100). At follow-up the mean diameter was 3.0xa0cm (range 1.20–4.5xa0cm), and the mean volume was 18xa0cm3 (range 0.90–47.6xa0cm3). In 10 of 11 patients we obtained total or partial regression of symptoms. In one case the clinical manifestations persisted and it was thus considered unsuccessful. In conclusion, US-guided percutaneous RFA is a safe and effective treatment even for fibroids up to 8xa0cm.

Microwave ablation therapy for treating primary and secondary lung tumours: technical note

PurposeThe purpose of our study was to retrospectively evaluate the feasibility, safety and effectiveness of microwave ablation (MWA) in nine patients with unresectable lung tumour.Materials and methodsTen lesions were treated in ten ablation sessions in nine patients. The treatments were performed with a microwave generator with 45 W and 915 MHz connected to a 14.5-gauge antenna for 10 min. Antenna placement was performed with computed tomography (CT) fluoroscopy guidance or XperGuide. All patients underwent CT follow-up at 1, 3 and 6 months from the procedure.ResultsTechnical success was obtained in all cases; mortality at 30 days was 0%.ConclusionsThis study shows that in selected patients, MWA is a valid alternative to other ablative techniques. Further studies are required to demonstrate the short- and long-term effects of this technique and to make a comparison with other available ablation systems, especially with radiofrequency.RiassuntoObiettivoLo scopo dello studio è stato quello di valutare il successo tecnico, la sicurezza, l’efficacia della metodica del trattamento ablativo mediante microonde (MW) in 9 pazienti affetti da neoplasia polmonare non trattabile chirurgicamente.Materiali e metodiSono state trattate 10 masse polmonari in 10 sessioni d’ablazione in 9 pazienti. È stato utilizzato un sistema ablativo costituito da un generatore di MW a 45 W e 915 MHz connesso ad un antenna 14,5 G, per un tempo di ablazione totale di 10 minuti. Il posizionamento dell’antenna è stato eseguito sotto guida fluoro-tomografia computerizzata (TC) o XperGuide. I pazienti sono stati sottoposti a follow-up mediante TC a 1, 3, 6 mesi dalla procedura.RisultatiSi è ottenuto un successo tecnico in tutti i casi; il tasso di mortalità a 30 giorni è stato dello 0%.ConclusioniQuesto studio dimostra che, in pazienti selezionati, la termoablazione con microonde rappresenta una valida alternativa ad altre tecniche ablative. Sono tuttavia necessari ulteriori studi per confermare a breve e lungo termine l’efficacia di questa metodologia e permettere un confronto con altri sistemi ablativi, in particolare rispetto alla radiofrequenza.

Comparison between MRI with spin-echo echo-planar diffusion-weighted sequence (DWI) and histology in the diagnosis of soft-tissue tumours

PurposeOur aim was to assess the usefulness of magnetic resonance imaging (MRI) with spin-echo echo-planar diffusion-weighted sequences (SE-EPI-DWI) in the study of primary and secondary soft-tissue tumours by correlating the results of imaging and histology.Material and methodsWe retrospectively studied 23 patients (14 men, 9 women; age range 25–87 years) affected by soft-tissue lesions. The MRI study was performed with baseline and contrast-enhanced SE-T1, proton density/T2-weighted (PD/T2), fat-saturated (FATSAT) DP/T2 and single-shot SE-EPI-DWI (b value 50-400- 800s/mm2) sequences.ResultsWe identified 7/23 benign lesions (three myxoid, four nonmyxoid) and 16/23 malignant tumours (four myxoid, 12 nonmyxoid) with a mean diameter between 21 mm and 20 cm. Qualitative analysis of DWI showed persistence of high signal intensity for increasing b-values in all malignant tumours. Quantitative DWI analysis of the apparent diffusion coefficient (ADC) maps showed a statistical difference between benign and malignant lesions.ConclusionsIn our experience, DWI with qualitative and quantitative analysis correlated well with histology.RiassuntoObiettivoScopo del nostro lavoro è stato valutare il ruolo della risonanza magnetica (RM) con sequenze spin echo (SE)-echo planar imaging (EPI)-diffusion-weighted imaging (DWI) nella caratterizzazione dei tumori primitivi e secondari dei tessuti molli, correlando i dati dell’imaging con i riscontri anatomopatologici.Materiali e metodiSono stati valutati retrospettivamente 23 pazienti (14 maschi, 9 femmine, età 25–87 anni) con neoformazione dei tessuti molli. Lo studio è stato eseguito mediante sequenze SE T1 prima e dopo somministrazione di mezzo di contrasto (MdC), DP/T2 con e senza saturazione del grasso (FAT SAT) e Single-Shot SE-EPI-DWI (b value: 50-400-800 s/mm2).RisultatiAbbiamo riscontrato 7/23 lesioni benigne (3 a matrice mixoide, 4 non mixoide) e 16/23 maligne (4 a matrice mixoide, 12 non mixoide), con diametro compreso tra 21 mm e 20 cm. L’analisi qualitativa della DWI ha dimostrato persistenza dell’iperintensità di segnale al crescere dei tre b value in tutte le lesioni maligne. L’analisi quantitativa della mappa del coefficiente apparente di diffusione (ADC) ha evidenziato una differenza statisticamente significativa dei valori di ADC tra lesioni benigne e maligne.ConclusioniNella nostra esperienza l’imaging DWI, attraverso la valutazione qualitativa del segnale e l’analisi quantitativa, ha mostrato buona correlazione con i rilievi istologici.

Non-enhanced MR angiography of renal arteries: comparison with contrast-enhanced MR angiography.

Background The main causes of renal artery stenosis (RAS) are atherosclerosis and fibromuscular dysplasia. Despite contrast-enhanced magnetic resonance angiography (CE-MRA) being a safe and reliable method for diagnosis of RAS especially in young individuals, recently it has been possible to adopt innovative technologies that do not require paramagnetic contrast agents. Purpose To assess the accuracy of steady-state free-precession (SSFP) non-contrast-enhanced magnetic resonance angiography (NC-MRA) by using a 1.5 T MR scanner for the detection of renal artery stenosis, in comparison with breath-hold CE-MRA as the reference standard. Material and Methods Sixty-three patients (33 men, 30 women) with suspected renovascular hypertension (RVHT) were examined by a 1.5T MR scanner; NC-MRA with an electrocardiography (ECG)-gated SSFP sequence was performed in 58.7% (37/63) of patients; in 41.3% (26/63) of patients a respiratory trigger was used in addition to cardiac gating. CE-MRA, with a three-dimensional gradient echo (3D-GRE) T1-weighted sequence, was performed in all patients within the same session. Maximum intensity projection (MIP) image quality, number of renal arteries, and the presence of stenosis were assessed by two observers (independently for NC-MRA and together for CE-MRA). The agreement between NC-MRA and CE-MRA as well as the inter-observer reproducibility were calculated with Bland-Altman plots. Results MIP image quality was considered better for NC-MRA. NC-MRA identified 143 of 144 (99.3%) arteries detected by CE-MRA (an accessory artery was not identified). Fourteen stenoses were detected by CE-MRA (11 atherosclerotic, 3 dysplastic) with four of 14 (28.5%) significant stenosis. Bland-Altman plot demonstrated an excellent concordance between NC-MRA and CE-MRA; particularly, the reader A evaluated correctly all investigated arteries, while over-estimation of two stenoses occurred for reader B. Regarding NC-MRA, inter-observer agreement was excellent. Conclusion NC-MRA is a valid alternative to CE-MRA for the assessment of renal arteries.

Ultrasound-guided injection of a corticosteroid and hyaluronic acid: A potential new approach to the treatment of trigger finger

AbstractBackground and Objectives: Stenosing tenosynovitis (trigger finger) is one of the most common causes of pain and disability in the hand, which may often require treatment with anti-inflammatory drugs, corticosteroid injection, or open surgery. However, there is still large room for improvement in the treatment of this condition by corticosteroid injection. The mechanical, viscoelastic, and antinociceptive properties of hyaluronic acid may potentially support the use of this molecule in association with corticosteroids for the treatment of trigger finger. This study examines the feasibility and safety of ultrasound-guided injection of a corticosteroid and hyaluronic acid compared, for the first time, with open surgery for the treatment of trigger finger.n Methods: This was a monocentric, open-label, randomized study. Consecutive patients aged between 35 and 70 years with ultrasound-confirmed diagnosis of trigger finger were included. Patients were randomly assigned to either ultrasound-guided injection of methylprednisolone acetate 40 mg/mL with 0.8mL lidocaine into the flexor sheath plus injection of 1mL hyaluronic acid 0.8% 10 days later (n = 15; group A), or to open surgical release of the first annular pulley (n = 15; group B). Clinical assessment of the digital articular chain was conducted prior to treatment and after 6 weeks, and 3, 6, and 12 months. The duration of abstention from work and/or sports activity, and any treatment complications or additional treatment requirements (e.g. physiotherapy, compression, medication) were also recorded.n Results: Fourteen patients (93.3%) in group A had complete symptom resolution at 6 months, which persisted for 12 months in 11 patients (73.3%), while three patients experienced recurrences and one experienced no symptom improvements. No patients in group A reported major or minor complications during or after corticosteroid injection, or required a compression bandage. All 15 patients in group B achieved complete resolution of articular impairment by 3 weeks after surgery, but ten patients were assigned to physiotherapy and local and/or oral analgesics for complete resolution of symptoms, which was approximately 30–40 days postsurgery. The mean duration of abstention from work and/or sport was 2–3 days in group A and 26 days in group B.n Conclusions: Although the limited sample size did not allow any statistical comparison between treatment groups, and therefore all the findings should be regarded as preliminary, the results of this explorative study suggest that ultrasound-guided injection of a corticosteroid and hyaluronic acid could be a safe and feasible approach for the treatment of trigger finger. It is also associated with a shorter recovery time than open surgery, which leads to a reduced abstention from sports and, in particular, work activities, and therefore may have some pharmacoeconomic implications, which may be further explored. In light of the promising results obtained in this investigation, further studies comparing ultrasound-guided injection of corticosteroid plus hyaluronic acid with corticosteroid alone are recommended in order to clarify the actual benefits attributable to hyaluronic acid.

Complications of percutaneous nephrostomy in the treatment of malignant ureteral obstructions: single-centre review.

Purpose.The purpose of this study was to evaluate the incidence and type of complications connected with percutaneous nephrostomy (PCN) deployment by comparing two different techniques.Materials and methods.In the last 3 years, 299 procedures of nephrostomy were performed on 201 patients (93 women, 108 men; mean age 65.7 years, range 32–102 years) at our Institute; all patients were affected by malignancy. In 44 cases (14.72%), patients presented grade IV hydronephrosis and in 255 cases (85.28%) grade II–III hydronephrosis. In 68 patients (23.07%), the procedure was carried out under emergency conditions because of the rapid worsening of renal function. All procedures were carried out in the angiography room, with the patient lying in a prone or prone–oblique position, under ultrasound and fluoroscopic guidance. Access to the pyelocalyceal system (intermediate or lower calices) was performed by using a Seldinger technique in 255/299 cases, or a one–step technique (OST) in 44 procedures when grade 4 hydronephrosis was present. Statistical analysis of results was performed using bilateral tests on proportions as well as χ2 test of independence for contingency tables.Results.We observed no major complications. All in all, the rate of minor complications was 3.01% (9/299 cases): 8/255 (3.13%) cases with the Seldinger technique; 1/44 (2.27%) with OST. We observed 43/299 (14.4%) dislodgements: 32/255 (10.70%) with the Seldinger technique and 11/44 (3,68%) with OST. In 4/299 (1.33%), rupture of the catheter occurred, and in 2/299 (0.67%), kinking occurred (in all cases with OST). From the statistical analysis, we conclude that the examination technique modifies the percentage of complications; in particular, it significantly (p<0.05) influences complications connected with the catheter but not minor complications. In addition, the system of fixing does not affect the percentage of dislodgements.Conclusions.PCN is a method with a high percentage of technical success with low rate of complications thanks to combined use of sonographic and fluoroscopic guidance for the procedure. The OST technique is indicated for a highly remarkable hydronephrosis and in cases where the catheter is only placed for a short period. The Seldinger technique is carried out in patients with grades II and III hydronephrosis and if the disease is predicted to have a long duration.

Initial experience with percutaneous biopsies of bone lesions using XperGuide cone-beam CT (CBCT): technical note

PurposeThis paper describes our preliminary experience with percutaneous bone biopsy under XperGuide conebeam computed tomography (CBCT) guidance.Materials and methodsSeventeen patients (11 men and 6 women; mean age 57.8; range 17–81) with 17 bone lesions underwent biopsy with XperGuide CBCT (Philips Medical System, Best, The Netherlands). The mean diameter of the lesions was 2.32 cm (range 1–8 cm). Technical success (defined as the correct positioning of the needle within the lesion), diagnostic accuracy, sensitivity and specificity were evaluated. Complication rate was also recorded.ResultsThe technical success rate was 100%. In 15 patients, a sample of adequate material for histopathological analysis to yield a definitive diagnosis was obtained; in two patients, the sample was inadequate for a definitive diagnosis. In one of these two cases, the lesion was closely followed up for 1 year, during which it remained stable in size, and as a result, it was considered a false positive; the other was considered a false negative. Diagnostic accuracy, sensitivity and specificity were 94.12%, 90.91% and 100%, respectively. No major complications were recorded; only one patient had slight bleeding, with a consequent small haematoma, which reabsorbed in about 15 days.ConclusionsBone biopsy under XperGuide CBCT guidance can be considered accurate as a result of the combination of real-time needle orientation and spatial resolution of CT fluoroscopy. Moreover, our results are encouraging in terms of complication rate, diagnostic accuracy, sensitivity, specificity and reduction of CT workload.RiassuntoObiettivoScopo del lavoro è descrivere la nostra esperienza preliminare delle biopsie ossee percutanee eseguite sotto guida XperGuide cone-beam (CBCT).Materiali e metodiDiciassette pazienti (11 maschi e 6 femmine; età media 57,8 anni, range 17–81) con 17 lesioni ossee sono stati sottoposti a biopsia percutanea con guida XperGuide CBCT. Il diametro medio delle lesioni era di 2,32 cm (range 1–8 cm). Sono stati valutati il successo tecnico (definito come il corretto posizionamento dell’ago all’interno della lesione), l’accuratezza diagnostica, la sensibilità e la specificità. è stata inoltre riportata la percentuale di complicanze.RisultatiIl successo tecnico è stato del 100%. In 15 pazienti, è stato ottenuto un campione di materiale adeguato per l’esame isto-patologico e per giungere ad una diagnosi definitiva; in 2 pazienti il campione è risultato inadeguato per giungere ad una diagnosi. In uno dei 2 casi, la lesione è stata seguita per un periodo di follow-up di 1 anno, durante il quale le sue dimensioni sono rimaste stabili; pertanto questa è stata considerata un falso positivo. L’altra è stata considerata un falso negativo. Accuratezza diagnostica, sensibilità e specificità erano rispettivamente del 94,12%, 90,91% e 100%. Non è stata registrata nessuna complicanza maggiore; solo un paziente ha presentato un lieve sanguinamento con un conseguente piccolo ematoma, assorbitosi spontaneamente in circa 15 giorni.ConclusioniLa biopsia ossea sotto guida XperGuide CBCT può essere considerata accurata grazie alla combinazione tra la possibilità di orientamento nello spazio real-time dell’ago e la risoluzione spaziale della fluoro-tomografia computerizzata (TC). Inoltre, i nostri risultati sono incoraggianti in termini di percentuale di complicanze, accuratezza diagnostica, sensibilità, specificità e non ultimo, riduzione del carico di lavoro del servizio TC.