Indravadan Patel

Image-guided cryoablation for the treatment of painful musculoskeletal metastatic disease: a single-center experience

PurposeThe role of image-guided thermal ablation techniques for the nonoperative local management of painful osseous metastatic disease has expanded during recent years, and several advantages of cryoablation in this setting have emerged. The purpose of this study is to retrospectively evaluate and report a single-center experience of CT-guided percutaneous cryoablation in the setting of painful musculoskeletal metastatic disease.MethodsThis study was approved by the institutional review board and is compliant with the Health Insurance Portability and Accountability Act. Electronic medical records of all patients who underwent percutaneous image-guided palliative cryoablation at our institution were reviewed (nu2009=u200961). An intent-to-treat analysis was performed. Records were reviewed for demographic data and anatomical data, primary tumor type, procedure details, and outcome—including change in analgesic requirements (expressed as morphine equivalent dosages), pain scores (utilizing the clinically implemented visual analog scale), subsequent therapies (including radiation and/or surgery), and complications during the 24xa0h following the procedure and at 3xa0months. Patients were excluded (nu2009=u20097) if data were not retrospectively identifiable at the defined time points.ResultsFifty-four tumors were ablated in 50 patients. There were statistically significant decreases in the median VAS score and narcotic usage at both 24xa0h and 3xa0months (pu2009<u20090.000). Six patients (11xa0%) incurred complications related to their therapy. Two patients had no relief at 24xa0h, of which both reported worsened pain at 3xa0months. One patient had initial relief but symptom recurrence at 3xa0months. Four patients went on to have radiation therapy of the ablation site at some point following the procedure.ConclusionsCT-guided cryoablation is a safe, effective, reproducible procedural option for the nonoperative local treatment of painful musculoskeletal metastatic disease.

Ablation zones and weight-bearing bones: points of caution for the palliative interventionalist.

PURPOSEnTo evaluate and classify underlying mechanisms of adverse outcomes after percutaneous computed tomography (CT)-guided cryoablation for palliation of painful musculoskeletal metastatic disease.nnnMATERIALS AND METHODSnData were collected for patients who underwent CT-guided percutaneous palliative cryoablation for painful musculoskeletal metastatic disease between January 2010 and December 2012. Cases with adverse outcomes or suboptimal response were identified and classified according to the Society of Interventional Radiology (SIR) classification system for complications by outcome and according to underlying mechanism of the outcome as delineated on follow-up examination.nnnRESULTSnThere were 61 patients who received ablation for painful musculoskeletal metastatic disease. Six patients with adverse outcomes were identified. Two were minor complications (A, n = 1; B, n = 1), and four were major complications (C, n = 1; D, n = 3). Four patients incurred sequelae related to damage of ancillary structures included in the ablation zone, and two patients developed complete fractures after ablation of lesions in weight-bearing bones.nnnCONCLUSIONSnComplete cryoablation of a painful musculoskeletal metastatic lesion may lead to ancillary damage of adjacent structures or fracture in weight-bearing bones.

Coblation for metastatic vertebral disease.

PURPOSEnPlasma-mediated radiofrequency ablation (coblation) creates a cavity for directed polymethylmethacrylate deposition through molecular dissociation, providing a safe and efficacious cementoplasty for patients with high-risk, painful vertebral body metastatic disease. The purpose of this study was to retrospectively review and report details regarding the feasibility, safety, and efficacy of coblation and cementoplasty for treating painful advanced vertebral body metastatic disease.nnnMATERIALS AND METHODSnFifteen patients with painful metastatic vertebral body fractures with a posterior cortical defect and/or epidural tumor extension underwent percutaneous coblation and cementoplasty. Each patients medical record was reviewed for technical success, imaging outcome, complications, and palliative effect.nnnRESULTSnOf the 15 cases, 14 were completed successfully. Postprocedure imaging studies demonstrated adequate cement deposition within the targeted vertebral body without cement extravasation or fracture progression during the 1-3 months follow-up period. Pain relief was achieved in all patients, and no neurological damage was reported (mean follow-up, 141.1 ± 132.5 days).nnnCONCLUSIONnPercutaneous image-guided coblation-mediated cavity creation prior to vertebroplasty allows for safe, efficacious cement deposition in patients with metastatic foci. Future studies prospectively comparing this procedure with other standard-of-care regimens are warranted.

Palliative Procedures for the Interventional Oncologist

OBJECTIVEnThe purpose of this article is to present our experience using multimodality interventional radiologic techniques for the treatment of cancer-related pain across a spectrum of abnormalities.nnnCONCLUSIONnPercutaneous imaging-guided thermal ablation has emerged as a safe and efficacious treatment for painful osseous metastases. The implementation of interventional thermal ablative techniques for the treatment of intractable pain secondary to malignancy can be further expanded to include transcatheter and combination procedures.

Contrast enhanced ultrasound guided biopsies of liver lesions not visualized on standard B-mode ultrasound—preliminary experience

BackgroundnTo assess the technical success of contrast enhanced ultrasound (CEUS) guided biopsies of liver lesions poorly visualized on B-mode ultrasound.nnnMethodsnPatients were selected during the procedure based on the real-time clinical scenario of unsatisfactory B-mode ultrasound lesion visualization and all patients would have otherwise undergone CT guided liver lesion biopsy. A total of 26 patients underwent CEUS guided biopsy and were included in this retrospective analysis. The review of the patients files included demographic information, lesion characteristics on imaging, procedural details and pathology outcome. Technical success was defined as concordance between the radiological findings, pathology report and clinical follow-up-demonstrating lack of need for re-biopsy or re-biopsy with identical pathological results. Patients with less than 2 months follow-up were excluded from the study.nnnResultsnCEUS guided liver biopsy was successful in 23 out of 26 patients (88.5%). The average procedure time was 30.7±12.3 minutes and the average lesion size was 2.2±1.7 cm. The majority of lesions (80.8%) were hypoenhancing on the delayed phase of CEUS. The mean number of samples taken from each lesion per procedure was 3.2 (±1.7).nnnConclusionsnCEUS guidance biopsies of focal liver lesions (FLL) that were difficult to visualize on B-mode ultrasound demonstrated high success rate and may be an evolving image guidance modality in selected patients to avoid CT guided procedures.

Real-time MRI-guided percutaneous sclerotherapy of low-flow head and neck lymphatic malformations in the pediatric population – a stepwise approach

Real-time MRI-guided percutaneous sclerotherapy is a novel and evolving treatment for congenital lymphatic malformations in the head and neck. We elaborate on the specific steps necessary to perform an MRI-guided percutaneous sclerotherapy of lymphatic malformations including pre-procedure patient work-up and preparation, stepwise intraprocedural interventional techniques and post-procedure management. Based on our institutional experience, MRI-guided sclerotherapy with a doxycycline-gadolinium-based mixture as a sclerosant for lymphatic malformations of the head and neck region in children is well tolerated and effective.

Real-time MRI-guided percutaneous sclerotherapy treatment of venous low-flow malformations in the head and neck

Purpose This manuscript describes the technique of real-time MRI-guided sclerotherapy for low-flow venous malformations in the head and neck based on our institutional experience. Materials and methods Ethanolamine oleate is used as the sclerosant and is mixed with gadolinium for visualization during the procedure. The five procedural steps include: (I) an initial tri-plane T2-weighted sequence to visualize the lesion; (II) a T1 FSE or trueFISP sequence to assess needle placement and advancement within the lesion; (III) a tri-plane T1 FLASH sequence to monitor sclerosant injection; (IV) a T1 FSE or VIBE sequence to assess sclerosant coverage of the malformation before needle removal; (V) a post-procedural tri-plane T1 fat-saturated sequence to confirm sclerosant coverage of the lesion. Periprocedural medications typically include steroids, antibiotic prophylaxis, and non-steroidal anti-inflammatory medication. Patients are typically admitted for overnight observation. Conclusion Real-time MRI-guided sclerotherapy for low-flow venous malformations in the head and neck is effective and safe.

Does Sleeve Shape Make a Difference in Outcomes

IntroductionSleeve gastrectomy (SG) is one of the most common procedures performed for weight loss. Many seek the “perfect sleeve” with the notion that the type of calibrating device affects sleeve shape, and this in turn will affect outcomes and complications. Two major concerns after SG are amount of weight loss and acid reflux. Our aim was to determine if the various calibration methods could impact sleeve shape and thereby allow for better outcomes of weight loss and reflux.MethodsA retrospective chart review was performed of 210 patients who underwent SG and had postoperative upper gastrointestinal (UGI) study from 2011 to 2015 in a single center by a single (fellowship-trained) bariatric surgeon. Data regarding demographics, calibrating devices and clinical outcomes at 1xa0year (weight loss and de novo acid reflux) were collected. UGIs were reviewed by two radiologists blinded to the clinical outcomes. Sleeve shape was classified according to a previously described classification as tubular, dumbbell, upper pouch, or lower pouch. The types of calibrating devices used to guide the sleeve size intraoperatively were endoscopy, large-bore orogastric tube, and fenestrated suction tube.ResultsOne hundred ninety-nine patients met inclusion criteria (11 had no esophagram). Demographics revealed age 45.76u2009±u200910.6xa0years, BMI 47u2009±u20098.6xa0kg/m2, and 82% female. Calibration devices used were endoscopic guidance (7.6%), large bore orogastric tube (41.4%), and fenestrated suction tube (50.5%). Sleeve shape was reported as 32.6% tubular, 20.6% dumbbell, 39.2% lower pouch, and 7.5% upper pouch (100% interrater reliability). No correlation was seen with type of calibration used. Of patients, 62.0% had >u200950% excess weight loss at 1xa0year. Twenty-three percent of patients remained on PPI at 1xa0year (of which 43.3% did not have reflux preoperatively). The lower pouch shape showed a trend toward less reflux and more weight loss.ConclusionThis study showed no clear association between uniformity of sleeve shape and the type of calibration device used. The study showed a trend toward decreased reflux and improved weight loss with the lower pouch shape, regardless of calibration device.

Multimodality imaging assessment of endoleaks post-endovascular aortic repair

Endoleaks are a common complication of endovascular aortic repair (EVAR). As a result, patients require lifelong imaging surveillance following EVAR. In current clinical practice, evaluation for endoleaks is predominantly performed with CT angiography (CTA). Due to the significant cumulative radiation burden associated with repetitive CTA imaging, as well as the repeated administration of nephrotoxic contrast agent, contrast-enhanced ultrasound (CEUS) and magnetic resonance angiography (MRA) have evolved as potential modalities for lifelong surveillance post-EVAR. In this paper, multimodality imaging, including CTA, CEUS and MRA, for the surveillance of endoleaks is discussed. Further, new CTA techniques for radiation reduction are elaborated. Additionally, imagery for three cases of aortic endoleak detection using CTA and five cases using MRA are presented. Imaging for different types of endoleaks with CTA, MRA and CEUS are presented. For lifelong endoleak surveillance post-EVAR, CTA is still regarded as the imaging modality of choice. However, advancements in CEUS and MRA technique enable partial replacement of CTA in certain patients.