Gianpaolo Carrafiello

Ultrasound-guided thermal radiofrequency ablation (RFA) as an adjunct to systemic chemotherapy for breast cancer liver metastases

PurposeThe aim of this study was to evaluate the effectiveness of radiofrequency thermal ablation (RFA) of liver metastases from breast cancer and its impact on survival.Materials and methodsThirteen female patients (age range 36–82 years; median 54.5 years) underwent RFA for the treatment of 21 liver metastases from breast cancer. The procedures were performed under ultrasound (US) guidance using an RF 2000 or RF 3000 generator system and Le Veen monopolar needle electrodes. Follow-up was carried out by computed tomography (CT) after 1, 3, 6 and 12 months.ResultsTechnical success was 100%. No major or minor complications occurred at the end of the procedure. In our series, 7/21 lesions in 7/13 patients increased in size at 7, 18, 19 and 38 months. This resulted in a mean disease-free interval of 16.6 months. Mean overall survival after RFA was 10.9 months.ConclusionsRFA appears to be a useful adjunct to systemic chemotherapy and/or hormone therapy in the locoregional treatment of hepatic metastases from breast cancer. RFA may also be a less invasive alternative to surgery in the locoregional treatment of liver metastases from breast cancerRiassuntoObiettivoScopo di questo studio è valutare l’efficacia della termoablazione con radiofrequenza (RFA) nel trattamento delle metastasi epatiche da tumore della mammella e il suo impatto sulla sopravvivenza.Materiali e metodiTredici pazienti (range 36–82 anni, età media 54,5 anni) sono state sottoposte a RFA di 21 metastasi epatiche da carcinoma della mammella. La procedura è stata eseguita utilizzando generatori RF 2000 o RF 3000 e sistema di aghi-elettrodi Le Veen monopolari. I controlli sono stati effettuati mediante tomografia computerizzata (TC) a 1, 3, 6, 9 e 12 mesi dopo la procedura.RisultatiÈ stato ottenuto un successo tecnico del 100%. Non si sono verificate complicanze peri- e postprocedurali. Nella nostra serie 7/21 lesioni in 7/13 pazienti sono aumentate dimensionalmente a 7, 18, 19 e a 38 mesi. L’intervallo libero da malattia è stato di 16,6 mesi. La media di sopravvivenza dopo radiofrequenza è stata di 10,9 mesi.ConclusioniLa RFA con effetto citoriduttivo, in pazienti con tumore della mammella rappresenta un’efficace metodica di trattamento, in aggiunta alla chemioterapia sistemica e all’ormonoterapia, delle metastasi epatiche. RFA rappresenta una valida alternativa alla chirurgia nel trattamento loco-regionale delle metastasi da tumore mammario.

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.

CT-guided biopsy of pulmonary nodules: is pulmonary hemorrhage a complication or an advantage?

PURPOSE We aimed to assess the correlation between pulmonary hemorrhage and pneumothorax in computed tomography (CT)-guided transthoracic fine needle aspiration (TTFNA), particularly its possible value as protection against the development of pneumotorax. MATERIALS AND METHODS We reviewed the CT images of 538 patients (364 males and 174 females, mean age 70 years, range 36-90 years) who underwent CT-guided TTFNA of pulmonary nodules between January 2008 and September 2013. The following CT findings were assessed: pulmonary hemorrhage (type 1, along the needle track; type 2, perilesional; low-grade, ≤6 mm; high-grade, >6 mm), pneumothorax, distance between the target nodule and the pleural surface, and emphysema. RESULTS Pneumothorax occurred in 154 cases (28.6%) and pulmonary hemorrhage occurred in 144 cases (26.8%). The incidence of pneumothorax was lower in patients showing type 1 and high-grade pulmonary hemorrhage pattern. The incidence of pneumothorax in biopsies ≥30 mm from pleural surface was 26% (12/46) in cases showing this pattern, while it was 71.4% (30/42) when this pattern was not seen. Similarly, the incidence of pneumothorax in biopsies <30 mm from the pleural surface was 0% (0/28) in cases showing this hemorrhage pattern, while it was 19% (76/394) when this pattern was not seen. CONCLUSION Pulmonary hemorrhage during TTFNA is a frequent event that protects against pneumothorax. A bleeding greater than 6 mm along the needle track is associated with lower incidence of pneumothorax, especially in biopsies deeper than 3 cm.

The role of interventional radiology in the treatment of intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary hepatic malignancy after hepatocellular carcinoma. Complete surgical resection remains the only potentially curative option for patients with ICC. However, until now, early diagnosis with potential surgical intervention has been the exception rather than the rule with only 30% of patients qualifying for attempted surgical cure. Many patients are unresectable because of disease stage, anatomic conditions, medical comorbidities, and small future remnant liver. Interventional radiology procedures are available for these types of patients with intra-arterial therapies and/or ablative treatments both for curative and for palliative treatment. The goals of interventional therapy are to control local tumor growth, to relieve symptoms, and to improve and preserve quality of life. The choice of treatment depends largely on tumor extent and patient performance. No randomized studies exist to compare treatments. The present review describes the current evidence of the interventional treatments in the management of the ICC. Moreover, interventional procedures available to increase the future liver reserve before surgery were analyzed.

The Role of Interventional Oncology in the Management of Lung Cancer

Interventional radiological procedures for diagnosis and treatment of lung cancer have become increasingly important. Imaging-guided percutaneous biopsy has become the modality of choice for diagnosing lung cancer, and in the era of target therapies, it is an useful tool to define earlier patient-specific tumor phenotypes. In functionally inoperable patients, especially the ablative procedures are potentially curative alternatives to surgery. In addition to thermally ablative treatment, selective chemoembolization by a vascular access allows localized therapy. These treatments are considered for patients in a reduced general condition which does not allow systemic chemotherapy. The present article reviews the role of interventional oncology in the management of primary lung cancer, focusing on the state of the art for each procedure.

The role of endovascular therapy in acute mesenteric ischemia

Background Endovascular therapy, including aspiration thrombectomy and local thrombolytic therapy, often associated with angioplasty and stent placement, has been described in the literature. The purpose of this study was to review case series of patients with acute mesenteric ischemia treated with endovascular therapy and evaluate their outcomes. Methods An online review using PubMed was carried out to identify all English articles about this topic in the time interval from 2005 to 2016. The following variables were extracted number of patients, cause of occlusion, symptoms, arteries involved, number of sessions of treatment, technical success, clinical success, recurrence rate, complications, mortality rate, number of patients who underwent diagnostic laparoscopy or surgical resection of ischemic bowel. Results Eighteen papers met the inclusion criteria and were included. Among the patients with arterial mesenteric ischemia treated with endovascular approach, the technical success rate was high (up to 100%) and data regarding clinical success are encouraging, even though they are few and heterogeneous. Technical success rate and clinical success of patients with acute venous mesenteric ischemia approached with endovascular treatment was 74-100% and 87.5-100% respectively. Conclusions Current advances in endovascular therapies have made these treatments feasible for mesenteric ischemia.

The role of ethylene–vinyl alcohol copolymer in association with other embolic agents for the percutaneous and endovascular treatment of type Ia endoleak

AimTo evaluate safety, technical and clinical success of embolization of type Ia endoleak (T1a EL) using ethylene–vinyl alcohol copolymer as embolic agent alone or in combination with other materials.Materials and methodsFive patients presented T1a EL after endovascular repair of aortic aneurysms (EVAR) with radiological evidence of expanding sac size; in particular, three had contained rupture. In one patient, proximal cuff insertion was previously performed, in three patients proximal cuff was urgently inserted but T1a EL persisted; one patient, previously treated with Ovation Abdominal Stent Graft System, was directly proposed for endovascular treatment. In all cases, endovascular embolization was successfully performed and the transfemoral approach was always chosen; in one case it failed and translumbar approach by direct puncture of the sac was required. Used embolization agents were glue, ethylene–vinyl alcohol copolymer (Onyx) and coils in three cases, n-butyl cyanoacrylate and Onyx in one case, Onyx and coils in the last case.ResultsTechnical success rate was 100% as well as clinical success. No major or minor complication, including non-target embolization, was registered. Clinical success was 100% until today and the sac diameter remained stable in four patients and decreased in one.ConclusionsOnyx may be considered a suitable embolic agent in the treatment of patients with type Ia endoleaks after EVAR, after failure of conventional treatments such as prolonged balloon inflation of the aortic neck or deployment of large bare stent.

Imaging Assessment of Thoracic Cage Injuries

Abstract Thoracic injuries are the third most common traumatic injury. Approximately two thirds of thoracic injuries are due to motor vehicle collisions. They are associated with up to a 20% mortality rate. This is primarily due to the presence of several complex anatomical structures within the thoracic cage such as the heart, great vessels, esophagus, airways, lungs, mediastinum, bones, muscles, diaphragm, and pleura. A chest radiograph is the initial imaging modality in the evaluation of the chest. However, multidetector computer tomography (MDCT) with intravenous contrast is the imaging modality of choice in the assessment of acute thoracic injuries. Endovascular repair is less invasive and has a better outcome than traditional surgical repair. This review article discusses the indications, benefits, and findings of radiographs and MDCT in patients with thoracic injuries, especially with regard to the thoracic aorta.

Central venous catheterization in fragile patients: which is the best approach?

We read with great interest the article published in your Journal by Rossi et al entitled “Percutaneous ultrasound-guided central venous catheters: the lateral in-plane technique for internal jugular vein access” that analyzes the state-of-the-art regarding the placement of central venous catheters (CVC) with internal jugular vein (IJV) access (1). Starting from the middle 1980s, ultrasound (US) guidance has been considered the standard procedure to cannulate the IJV. Its main advantage is the real-time visualization of the needle, the vein, and the surrounding structures, improving the rate of cannulation at first attempt as well as reducing the rate of complications (1). Furthermore, prior to insertion, US can be used to check patency of the IJV as well as its structure. In particular, the operator should search for thrombi or stenosis in the IJV or for congenital anomalies of the superior vena cava, as a thrombus can lead to pulmonary embolism when the catheter is positioned (2), while stenosis or vascular anomalies may prevent the success of cannulation (3). However, some complications can still occur during the procedure, such as vascular injury, pneumothorax, malposition, thrombosis, infection or kinking of the catheter. We agree with the authors when they say that the lateral short axis is the best way to reach the vein, as it allows to follow the needle in plane, and to check the surrounding structures at the same time, avoiding puncture of the carotid artery as well as laceration of the vessels. Furthermore, even the catheter kinking can be prevented with a lateral access to the IJV, as the catheter comes out of the vein gently, without changing its angle (1). Of note, even if the lateral access to the IJV represents a good approach to cannulate a central vein, the authors did not mention the possibility of choosing other sites of puncture, such as the subclavian vein. In the literature there is no concordance regarding the best site of cannulation and probably the two approaches are superimposable in terms of complication rate (2). Anyway, the subclavian approach is not recommended when dealing with large caliber CVCs, such as those used in hemodialysis settings, because of an increased risk of thrombosis in comparison to the IJV access (4). An approach as atraumatic as possible to the vascular system of dialysis patients is of pivotal importance, as they have to continue therapy for a long or indefinite time. Lacerations of the vein during cannulation can lead to thrombosis and consequently to malfunction of the catheter (5), which then requires a replacement. In that case, in order to preserve the vascular patency, the catheter should be replaced at the same access (4). Furthermore, thrombosis reduces the flow within the vein, compromising the possibility of making a permanent arteriovenous fistula (6) on that site. As for dialysis patients, it is mandatory to have a continuous treatment and the operator should make every attempt to avoid the loss of multiple vascular accesses in those patients, as options of treatment are still limited (7). In conclusion, even though the positioning of a CVC is usually safe and effective, it should be performed by well-trained operators who have to keep in mind the clinical relevance of their choices, in particular for patients affected by multiple comorbidities.

Percutaneous management of bone metastases: state of the art, interventional strategies and joint position statement of the Italian College of MSK Radiology (ICoMSKR) and the Italian College of Interventional Radiology (ICIR)

Interventional radiology provides local management of bone metastases (BM) with a palliative intent in most cases, or with a curative intent in selected patients. Its role has rapidly expanded in the last decade, offering new treatment solutions often in combination with surgery, radiation therapy and medical treatments. The aim of the present paper is to increase awareness, acceptance and adoption of interventional radiology procedures for the treatment of BM; and to present the joint position of the Italian College of Musculoskeletal Radiology and the Italian College of Interventional Radiology.