Maria Franca Meloni

Image-guided Tumor Ablation: Standardization of Terminology and Reporting Criteria—A 10-Year Update

Image-guided tumor ablation has become a well-established hallmark of local cancer therapy. The breadth of options available in this growing field increases the need for standardization of terminology and reporting criteria to facilitate effective communication of ideas and appropriate comparison among treatments that use different technologies, such as chemical (eg, ethanol or acetic acid) ablation, thermal therapies (eg, radiofrequency, laser, microwave, focused ultrasound, and cryoablation) and newer ablative modalities such as irreversible electroporation. This updated consensus document provides a framework that will facilitate the clearest communication among investigators regarding ablative technologies. An appropriate vehicle is proposed for reporting the various aspects of image-guided ablation therapy including classification of therapies, procedure terms, descriptors of imaging guidance, and terminology for imaging and pathologic findings. Methods are addressed for standardizing reporting of technique, follow-up, complications, and clinical results. As noted in the original document from 2003, adherence to the recommendations will improve the precision of communications in this field, leading to more accurate comparison of technologies and results, and ultimately to improved patient outcomes. Online supplemental material is available for this article .

Image-guided tumor ablation: standardization of terminology and reporting criteria--a 10-year update.

Image-guided tumor ablation has become a well-established hallmark of local cancer therapy. The breadth of options available in this growing field increases the need for standardization of terminology and reporting criteria to facilitate effective communication of ideas and appropriate comparison among treatments that use different technologies, such as chemical (eg, ethanol or acetic acid) ablation, thermal therapies (eg, radiofrequency, laser, microwave, focused ultrasound, and cryoablation) and newer ablative modalities such as irreversible electroporation. This updated consensus document provides a framework that will facilitate the clearest communication among investigators regarding ablative technologies. An appropriate vehicle is proposed for reporting the various aspects of image-guided ablation therapy including classification of therapies, procedure terms, descriptors of imaging guidance, and terminology for imaging and pathologic findings. Methods are addressed for standardizing reporting of technique, follow-up, complications, and clinical results. As noted in the original document from 2003, adherence to the recommendations will improve the precision of communications in this field, leading to more accurate comparison of technologies and results, and ultimately to improved patient outcomes.

Breast Cancer Liver Metastases: US-guided Percutaneous Radiofrequency Ablation—Intermediate and Long-term Survival Rates

PURPOSE To retrospectively assess the local control and intermediate- and long-term survival of patients with liver metastases from breast cancer who have undergone percutaneous ultrasonography (US)-guided radiofrequency (RF) ablation. MATERIALS AND METHODS This study was approved by the hospital ethics committee, and all patients provided written informed consent. RF ablation was used to treat 87 breast cancer liver metastases (mean diameter, 2.5 cm) in 52 female patients (median age, 55 years). Inclusion criteria were as follows: fewer than five tumors, maximum tumor diameter of 5 cm or smaller, and disease either confined to the liver or stable with medical therapy. Forty-five (90%) of 50 patients had previously undergone chemotherapy, hormonal therapy, or both, and had no response or an incomplete response to the treatment. Contrast material-enhanced computed tomography and US were performed to evaluate complications and technical success and to assess for local tumor progression during follow-up. The Kaplan-Meier method was used to assess survival, and results were compared between groups with a log-rank test. Cox regression analysis was used to assess independent prognostic factors that affected survival. RESULTS Complete tumor necrosis was achieved in 97% of tumors. Two (4%) minor complications occurred. Median time to follow-up from diagnosis of liver metastasis and from RF ablation was 37.2 and 19.1 months, respectively. Local tumor progression occurred in 25% of patients. New intrahepatic metastases developed in 53% of patients. From the time of first RF ablation, overall median survival time and 5-year survival rate were 29.9 months and 27%, respectively. From the time the first liver metastasis was diagnosed, overall median survival time was 42 months, and the 5-year survival rate was 32%. Patients with tumors 2.5 cm in diameter or larger had a worse prognosis (hazard ratio, 2.1) than did patients with tumors smaller than 2.5 cm in diameter. CONCLUSION Survival rates in selected patients with breast cancer liver metastases treated with RF ablation are comparable to those reported in the literature that were achieved with surgery or laser ablation.

Follow-up after percutaneous radiofrequency ablation of renal cell carcinoma: contrast-enhanced sonography versus contrast-enhanced CT or MRI.

OBJECTIVE The purpose of this study was to assess, with contrast-enhanced CT or MRI as the reference imaging technique, the diagnostic performance of low-mechanical-index contrast-enhanced sonography in detecting local tumor progression after percutaneous radiofrequency ablation of renal tumors. MATERIALS AND METHODS Twenty-nine patients with 30 renal tumors (18 men, 11 women; mean age, 73 years; range, 53-83 years) underwent percutaneous radiofrequency ablation at a single center between March 1998 and January 2007. The imaging follow-up schedule was both contrast-enhanced sonography and CT or MRI 4 months after completion of treatment and every 4 months for the first year. Thereafter, the follow-up schedule was contrast-enhanced sonography every 4 months with CT or MRI every 8 months. The chi-square test with Yates correction was used to evaluate positive and negative predictive values and accuracy. RESULTS One patient was scheduled to undergo surgical resection, and another patient was lost to follow-up. Twenty-seven patients with 28 renal tumors participated in follow-up. The concordance between contrast-enhanced sonographic and CT or MRI findings was 100% for 27 of 28 tumors (96.4%) that had a hypervascular pattern before treatment. In the case of the tumor that was hypovascular at imaging performed before percutaneous radiofrequency ablation, local tumor progression was missed at contrast-enhanced sonography. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of contrast-enhanced sonography were 96.6%, 100%, 100%, 95.8%, and 98.1%. CONCLUSION Contrast-enhanced sonography is an effective alternative to CT and MRI in the follow-up of renal tumors managed with percutaneous radiofrequency ablation.

Sonographic training program at a district hospital in a developing country: work in progress.

OBJECTIVE The purposes of this study were to assess the feasibility of a sonographic training program at a district hospital in a developing country and to evaluate the effect of the program on public health care services. SUBJECTS AND METHODS A sonographic training program is being conducted on Pemba Island, Tanzania. A maximum of 10 trainees participate in the program. Courses in sonography conducted by European physicians are scheduled every 4 months for 2 consecutive weeks each time. The sonographic training program lasts 5 years and is divided into three stages in which basic, advanced, and specialized courses are organized. At the end of every course, the trainees take a multiple-choice test (score, 1-10) and a practical test with patients (score, 1-5). To advance to the next stage, a trainee needs a score of at least 7 on the theory test and at least 3 on the practical. RESULTS Three courses have been completed. The total mean scores on the multiple-choice test were 7.4 (range, 6.5-9) at the end of the first course, 7.3 (range, 6.5-8.5) at the end of the second course, and 6.2 (range, 4.0-9.5) at the end of the third course. A shortage of electricity hindered the practical test after the first and second courses. At the end of the third course, the total mean score on the practical was 3.5 (range, 1.5-5.0). Seven of 10 trainees were admitted to the second year of the sonographic training program. The mean monthly hospital earnings during the three-course period were 673,200 Tanzanian shillings. CONCLUSION Sonography is an affordable technology for developing countries. Training in sonography should be included in the planning of long-term projects in which multiple access and feedback are provided in the same area.

The EFSUMB Guidelines and Recommendations for the Clinical Practice of Contrast-Enhanced Ultrasound (CEUS) in Non-Hepatic Applications: Update 2017 (Long Version)

The updated version of the EFSUMB guidelines on the application of non-hepatic contrast-enhanced ultrasound (CEUS) deals with the use of microbubble ultrasound contrast outside the liver in the many established and emerging applications.

Microwave ablation in primary and secondary liver tumours: technical and clinical approaches.

Abstract Thermal ablation is increasingly being utilised in the treatment of primary and metastatic liver tumours, both as curative therapy and as a bridge to transplantation. Recent advances in high-powered microwave ablation systems have allowed physicians to realise the theoretical heating advantages of microwave energy compared to other ablation modalities. As a result there is a growing body of literature detailing the effects of microwave energy on tissue heating, as well as its effect on clinical outcomes. This article will discuss the relevant physics, review current clinical outcomes and then describe the current techniques used to optimise patient care when using microwave ablation systems.

Microwave ablation of primary and secondary liver tumours: ex vivo, in vivo, and clinical characterisation

Abstract Purpose: The aim of this study was to compare the performance of a microwave ablation (MWA) apparatus in preclinical and clinical settings. Materials and method: The same commercial 2.45 GHz MWA apparatus was used throughout this study. In total 108 ablations at powers ranging from 20 to 130 W and lasting from 3 to 30 min were obtained on ex vivo bovine liver; 28 ablations at 60 W, 80 W and 100 W lasting 5 and 10 min were then obtained in an in vivo swine model. Finally, 32 hepatocellular carcinomas (HCCs) and 19 liver metastases in 46 patients were treated percutaneously by administering 60 W for either 5 or 10 min. The treatment outcome was characterised in terms of maximum longitudinal and transversal axis of the induced ablation zone. Results: Ex vivo ablation volumes increased linearly with deposited energy (r2 = 0.97), with higher sphericity obtained at lower power for longer ablation times. Larger ablations were obtained on liver metastases compared to HCCs treated with 60 W for 10 min (p < 0.003), as ablation diameters were 4.1 ± 0.6 cm for metastases and 3.7 ± 0.3 cm for HCC, with an average sphericity index of 0.70 ± 0.04. The results on the in vivo swine model at 60 W were substantially smaller than the ex vivo and clinical results (either populations). No statistically significant difference was observed between ex vivo results at 60 W and HCC results (p > 0.08). Conclusions: For the selected MW ablation device, ex vivo data on bovine liver was more predictive of the actual clinical performance on liver malignancies than an in vivo porcine model. Equivalent MW treatments yielded a significantly different response for HCC and metastases at higher deposited energy, suggesting that outcomes are not only device-specific but must also be characterised on a tissue-by-tissue basis.

Contrast enhanced ultrasound in the evaluation and percutaneous treatment of hepatic and renal tumors

Image-guided percutaneous ablation techniques are increasingly being used for the treatment of malignant tumors of the liver and kidney. Contrast enhanced ultrasound (CEUS) is a real-time dynamic imaging technique that plays an important role in the pre-, intra-, and post-procedural management of these patients. This review will focus on the role of CEUS in the evaluation of patients undergoing treatment with percutaneous ablation for hepatic or renal tumors.

Percutaneous Ethanol Injection

The chapter considers the principles, the techniques, the results of PEI for treating cirrhotic patients with HCC, and its current indications compared to those of RF, which is now considered the gold standard.