Jeffrey P. Guenette

Radiofrequency ablation of colorectal hepatic metastases.

Radiofrequency ablation (RFA) may be performed intraoperatively, laparoscopically, or percutaneously. The percutaneous approach is associated with the least procedural risk and may be performed under local anesthesia. Percutaneous RFA should be considered a primary treatment option for patients with unresectable hepatic tumors or conditions that prohibit general anesthesia or abdominal surgery. Continually improving thermal ablation and imaging technologies are likely to further increase tumor ablation efficacy and expand its role in treatment of hepatic metastases. J. Surg. Oncol. 2010;102:978–987.

Image-guided ablation of postsurgical locoregional recurrence of biopsy-proven well-differentiated thyroid carcinoma.

PURPOSE To evaluate the clinical outcomes of ultrasound-guided percutaneous radiofrequency (RF) ablation and percutaneous ethanol injection (PEI) as salvage therapy for locoregional recurrence after resection of well-differentiated thyroid carcinoma. MATERIALS AND METHODS There were 42 locoregional, biopsy-proven, papillary and follicular thyroid carcinoma lesions (0.5-3.7 cm) treated, 21 with RF ablation and 21 with PEI. Of treated lesions, 35 were located in the lateral compartments, and 7 were located in the central compartment. Data points in the retrospective analysis, determined beforehand by the investigators, were progression at the ablation site, serum thyroglobulin levels before and after the procedure, and procedural complications. RESULTS Average follow-up after RF ablation was 61.3 months and after PEI was 38.5 months. No progression was detected in the region of ablation for any of the lesions treated with RF ablation. Local progression was detected 4-11 months after ablation in 5 of the 21 lesions treated with PEI, 3 in the lateral compartment and 2 in the central compartment; all of the lesions were successfully retreated with repeat PEI, RF ablation, or surgery. Permanent vocal cord paralysis occurred after one RF ablation procedure of a lateral compartment supraclavicular node. There were no complications after PEI. CONCLUSIONS This case series provides long-term follow-up evidence of the safety and efficacy of ultrasound-guided RF ablation and PEI for control of locoregional recurrence of well-differentiated thyroid carcinoma after surgery.

Solitary Painful Osseous Metastases: Correlation of Imaging Features with Pain Palliation after Radiofrequency Ablation—A Multicenter American College of Radiology Imaging Network Study

PURPOSE To identify the correlation of pre- and postablation imaging features with pain relief, pain intensity, and patient mood after radiofrequency (RF) ablation of solitary painful osseous metastases. MATERIALS AND METHODS This prospective, multicenter group trial was approved by each institutional review board. Participants were enrolled between November 1, 2001, and April 6, 2006. Written informed consent was obtained from all subjects, and patient confidentiality protocols were followed in compliance with HIPAA. Computed tomography (CT)-guided RF ablation and contrast material-enhanced 1-month follow-up CT and/or magnetic resonance imaging were performed in 49 subjects (24 men, 25 women; age range, 34-83 years) with a confirmed malignant solitary bone lesion of maximum dimension of 8 cm or smaller that was causing intractable pain. Pain intensity and patient mood were measured before and after RF ablation. Tumor imaging features were recorded. Unadjusted and adjusted linear mixed-effects models, with a random intercept for each subject, were used to model patient mood, pain relief, and pain intensity scores at three times after ablation as a function of each tumor characteristic. RESULTS Decreased postablation tumor pain correlated with preablation tumor volume (P = .02) and pathologic fracture (P = .01), while pain relief correlated with pathologic fracture (P = .03) and percentage of bone-tumor interface (BTI) ablated (P = .02). Conversely, presence of an irregular rim after ablation (P = .02) and rim thickness (P = .01) correlated with increased pain. There was no evidence in this study that RF ablation of larger tumor percentage or larger volume leads to better pain relief or decreased pain (P > .05). CONCLUSION Existing pathologic fracture and smaller tumor size appear to be predictive parameters of success when selecting patients for palliative RF ablation of painful solitary osseous metastases. Successful palliation also appears to be related to the percentage of BTI ablated.

Burnout: Prevalence and Associated Factors Among Radiology Residents in New England With Comparison Against United States Resident Physicians in Other Specialties

OBJECTIVE The objective of our study was to establish burnout prevalence, associated demographic and program-related factors, and degree of burnout in New England radiology residents relative to residents in other specialties. MATERIALS AND METHODS A 31-item survey, including nine demographic and program-related questions and the 22-item Maslach Burnout Inventory-Health Services Survey, was sent to all resident members of the New England Roentgen Ray Society (20 programs, 472 residents). Emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA) scores were calculated and stratified using published normative data. Multiple linear regression analysis was performed to identify burnout predictors. Chi-square testing with Bonferroni correction was performed to confirm predictors associated with high burnout. The EE, DP, and PA scores were compared with the results of residents from other specialties. RESULTS There were 94 responses. High EE, high DP, and low PA scores were reported by 37%, 48%, and 50% of respondents, respectively. EE, DP, and PA scores and rates were low relative to those reported across specialties. Increasing residency year correlated with high EE (p = 0.002) and high DP (p < 0.001). No other factor significantly correlated with burnout. CONCLUSION A high degree of burnout, increasing over the postgraduate years, was present in more than one-third of responding radiology residents but was present in a smaller percentage relative to residents across other specialties. Radiology residents score relatively poorly in PA and therefore addressing PA may be central to improving burnout symptoms overall.

Computer-Based Vertebral Tumor Cryoablation Planning and Procedure Simulation Involving Two Cases Using MRI-Visible 3D Printing and Advanced Visualization.

OBJECTIVE We report the development and use of MRI-compatible and MRI-visible 3D printed models in conjunction with advanced visualization software models to plan and simulate safe access routes to achieve a theoretic zone of cryoablation for percutaneous image-guided treatment of a C7 pedicle osteoid osteoma and an L1 lamina osteoblastoma. Both models altered procedural planning and patient care. CONCLUSION Patient-specific MRI-visible models can be helpful in planning complex percutaneous image-guided cryoablation procedures.

Nonhemorrhagic Adrenal Infarction With Magnetic Resonance Imaging Features During Pregnancy.

BACKGROUND: Adrenal infarction is an infrequent cause of severe abdominal pain during pregnancy. The magnetic resonance imaging (MRI) features of adrenal infarction have not previously been thoroughly described. CASES: A 20-year-old woman, gravida 1 para 0, presented at 27 4/7 weeks of gestation with sudden-onset right upper quadrant and flank pain. A 29-year-old woman, gravida 2 para 1, presented at 17 5/7 weeks of gestation with sudden-onset right abdominal and flank pain and again at 35 5/7 weeks of gestation with sudden-onset severe left flank and upper quadrant pain. In both patients, unilateral adrenal infarction was diagnosed on contrast-enhanced computed tomography after initial nondiagnostic ultrasonography and MRI. Clinical presentation and MRI features of nonhemorrhagic adrenal infarction are described. CONCLUSION: Nonhemorrhagic adrenal infarction may be an underdiagnosed cause of acute abdominal pain during pregnancy and can be diagnosed with MRI.

Spine Cryoablation: A Multimodality Image-Guided Approach for Tumors Adjacent to Major Neural Elements

SUMMARY: We report percutaneous cryoablation of spine tumors in 7 consecutive patients (5 men, 2 women [mean age, 47 years; range, 17–68 years]) by using intraprocedural image monitoring of ice ball margins to protect adjacent neural elements. Complete tumor ablation was achieved in all patients without neurologic complication. Pain relief was achieved in 4 of 5 (80%) patients; the patient with persistent pain was later found to have enlarging metastases at other sites.

Percutaneous Image-Guided Cryoablation of Head and Neck Tumors for Local Control, Preservation of Functional Status, and Pain Relief

OBJECTIVE We report nine consecutive percutaneous image-guided cryoablation procedures of head and neck tumors in seven patients (four men and three women; mean age, 68 years; age range, 50-78 years). Ablation of the entire tumor for local control or ablation of a region of tumor for pain relief or preservation of function was achieved in eight of nine procedures. One patient experienced intraprocedural bradycardia, and another developed a neopharyngeal abscess. There were no deaths, permanent neurologic or functional deficits, vascular complications, or adverse cosmetic sequelae due to the procedures. CONCLUSION Percutaneous image-guided cryoablation offers a potentially less morbid minimally invasive treatment option than salvage head and neck surgery. The complications that we encountered may be avoidable with increased experience. Further work is needed to continue improving the safety and efficacy of cryoablation of head and neck tumors and to continue expanding the use of cryoablation in patients with head and neck tumors that cannot be treated surgically.

MRI Findings in Patients With Leukemia and Positive CSF Cytology: A Single-Institution 5-Year Experience.

OBJECTIVE The purposes of this study were to describe the spectrum of MRI findings and determine the prognostic role of MRI in adults with acute leukemia with positive CSF cytology. MATERIALS AND METHODS In this retrospective study of 34 patients (19 women, 15 men; mean age, 51 years; range, 18-72 years) treated for CNS leukemia between 2006 and 2011, 31 (91%) contrast-enhanced brain and 14 (41%) spine MRI studies were reviewed by two radiologists to note patterns of enhancement. Interobserver agreement and correlation of enhancement with outcome were analyzed. RESULTS MRI showed abnormal findings in 25 patients (74%). Pachymeningeal enhancement (n = 9/31, 29%), leptomeningeal enhancement (n = 6/31, 19%), cranial nerve enhancement (n = 9/31, 29%), masslike enhancement (n = 3/31, 10%), and spinal meningeal enhancement (n = 10/14, 71%) were identified. There was strong interobserver agreement (κ = 0.906). Survival rates were shorter to a statistically significant degree with pachymeningeal enhancement (median, 7 months; interquartile range [IQR], 5-8 months versus median, 26 months; IQR, 15 months to not reached; p = 0.004) and two or more sites of enhancement (median, 8 months; IQR, 3-13 months versus median, 19 months; IQR, 9 months to not reached; p = 0.046). CONCLUSION Brain or spine MRI examinations (or both) showed abnormal findings in nearly three-fourths of adults with acute leukemia with positive CSF cytology who were imaged for neurologic symptoms. Pachymeningeal enhancement and two or more sites of brain involvement were associated with shorter survival.

Imaging of Concussion in Young Athletes

Conventional neuroimaging examinations are typically normal in concussed young athletes. A current focus of research is the characterization of subtle abnormalities after concussion using advanced neuroimaging techniques. These techniques have the potential to identify biomarkers of concussion. In the future, such biomarkers will likely provide important clinical information regarding the appropriate time interval before return to play, as well as the risk for prolonged postconcussive symptoms and long-term cognitive impairment. This article discusses results from advanced imaging techniques and emphasizes imaging modalities that will likely become available in the near future for the clinical evaluation of concussed young athletes.