Michael A. Farrell

Percutaneous Image-Guided Radiofrequency Ablation of Painful Metastases Involving Bone: A Multicenter Study

PURPOSE Few options are available for pain relief in patients with bone metastases who fail standard treatments. We sought to determine the benefit of radiofrequency ablation (RFA) in providing pain relief for patients with refractory pain secondary to metastases involving bone. PATIENTS AND METHODS Thirty-one US and 12 European patients with painful osteolytic metastases involving bone were treated with image-guided RFA using a multitip needle. Treated patients had > or = 4/10 pain and had either failed or were poor candidates for standard treatments such as radiation or opioid analgesics. Using the Brief Pain Inventory-Short Form, worst pain intensity was the primary end point, with a 2-unit drop considered clinically significant. RESULTS Forty-three patients were treated (median follow-up, 16 weeks). Before RFA, the mean score for worst pain was 7.9 (range, 4/10 to 10/10). Four, 12, and 24 weeks following treatment, worst pain decreased to 4.5 (P <.0001), 3.0 (P <.0001), and 1.4 (P =.0005), respectively. Ninety-five percent (41 of 43 patients) experienced a decrease in pain that was considered clinically significant. Opioid usage significantly decreased at weeks 8 and 12. Adverse events were seen in 3 patients and included (1) a second-degree skin burn at the grounding pad site, (2) transient bowel and bladder incontinence following treatment of a metastasis involving the sacrum, and (3) a fracture of the acetabulum following RFA of an acetabular lesion. CONCLUSION RFA of painful osteolytic metastases provides significant pain relief for cancer patients who have failed standard treatments.

Image-guided ablation of painful metastatic bone tumors: a new and effective approach to a difficult problem.

Painful skeletal metastases are a common problem in cancer patients. Although external beam radiation therapy is the current standard of care for cancer patients who present with localized bone pain, 20–30% of patients treated with this modality do not experience pain relief, and few further options exist for these patients. For many patients with painful metastatic skeletal disease, analgesics remain the only alternative treatment option. Recently, image-guided percutaneous methods of tumor destruction have proven effective for treatment of this difficult problem. This review describes the application, limitations, and effectiveness of percutaneous ablative methods including ethanol, methyl methacrylate, laser-induced interstitial thermotherapy (LITT), cryoablation, and percutaneous radiofrequency ablation (RFA) for palliation of painful skeletal metastases.

Percutaneous Renal Cryoablation: Experience Treating 115 Tumors

PURPOSE We determined technical feasibility, safety and short-term outcomes following percutaneous renal cryoablation. MATERIALS AND METHODS We performed a retrospective review of 115 renal tumors in 110 patients treated with percutaneous cryoablation. Specific attention was directed to tumor characteristics, hospital course, complications, technical success and treatment success based on followup imaging. RESULTS Mean tumor size was 3.3 cm (range 1.5 to 7.3), including 29 tumors 4.0 cm or larger and 21 tumors in the anterior kidney. Of 90 renal mass biopsies performed 52 (58%) showed renal cell carcinoma. All patients were admitted to the hospital following cryoablation and most (87%) were discharged home the next day (range 1 to 12 days). There were 7 major complications associated with the 113 cryoablation procedures (6%). Technical success was achieved in 112 of the 115 (97%) treated tumors and 3 residual tumors were seen on 3-month followup imaging. There has been no local progression in 80 tumors (100% treatment success) followed 3 months or longer (mean 13.3 months). CONCLUSIONS Percutaneous renal cryoablation is technically feasible and relatively safe. With experience many anterior tumors and tumors larger than 4 cm can be successfully treated. Long-term followup remains necessary to prove treatment durability.

Percutaneous Cryoablation of Large Renal Masses: Technical Feasibility and Short-Term Outcome

OBJECTIVE This retrospective study was performed to assess the feasibility, safety, and short-term outcome of percutaneous cryoablation of large solid renal tumors. MATERIALS AND METHODS We reviewed 40 percutaneous cryoablation procedures performed on 40 patients with renal tumors 3 cm in diameter or larger. All patients underwent cryoablation with CT monitoring. Technical success was defined by extension of the ice ball beyond the tumor margin and postablation imaging findings of no contrast enhancement in the area encompassing the original tumor. Complications meeting grade 3 of the National Cancer Institute Common Terminology Criteria for Adverse Events were recorded. RESULTS Mean +/- SD tumor diameter was 4.2 +/- 1.1 cm (range, 3.0-7.2 cm). Technical success was achieved in 38 (95%) of 40 cryoablation procedures. There was one grade 3 adverse event (3% rate of significant complications). Follow-up images obtained 3 months or longer (mean, 9 +/- 6 months; range, 3-22 months) after ablation were available for 26 (65%) of the 40 patients. No local tumor recurrence or tumor progression was found. CONCLUSION Percutaneous cryoablation of renal tumors measuring 3 cm or larger is technically feasible and relatively safe. Short-term follow-up results are encouraging, although long-term follow-up is necessary to assess true treatment efficacy.

Inflammatory pseudotumor of the spleen associated with a clonal Epstein-Barr virus genome: Case report and review of the literature

We report a case of an inflammatory pseudotumor (IPT) of the spleen occurring in an 81-year-old woman with a history of a monoclonal gammopathy of undetermined significance. Eighteen-month follow-up after splenectomy demonstrated no tumor recurrence or progression of underlying plasma cell disease. Histologic examination of the tumor demonstrated a polymorphic population of inflammatory and epithelioid and spindle cells. Immunophenotyping showed large numbers of T cells, B cells, and polyclonal plasma cells. The epithelioid and spindle cells were positive for vimentin and CD68 but lacked expression of follicular dendritic cell markers and actin. Epstein-Barr virus (EBV) genome was identified in the epithelioid and spindle cell population by in situ hybridization using probes specific for EBV-encoded RNAs (EBER1 and EBER2). Southern blot analysis of digested DNA extracted from the tumor using an EBV-specific probe (XhoI) demonstrated the presence of a single high-intensity band, indicative of EBV monoclonality. While there have been 2 previous reports of hepatic IPTs containing a monoclonal population of EBV-infected tumor cells, this is the first report of such an association occurring in the spleen. The presence of clonal EBV DNA suggests some splenic IPTs may be true neoplasms.

Percutaneous Renal Cryoablation: Local Control at Mean 26 Months of Followup

PURPOSE We retrospectively determined the efficacy of percutaneous renal cryoablation based on a mean followup of more than 2 years. MATERIALS AND METHODS Institutional review board approval was obtained for this Health Insurance Portability and Accountability Act compliant retrospective study. Informed consent was waived. From March 2003 through March 2007, 91 patients with 93 tumors underwent 92 percutaneous cryoablation procedures. Technical success was defined as extension of the ice ball beyond the tumor margin and post-ablation images showing no contrast enhancement in the area encompassing the original tumor within 3 months of the procedure. Local tumor progression was defined as new enhancement in the ablated tumor or an increase in ablated tumor size beyond 3 months after the procedure. Complications were defined using the National Cancer Institute Common Terminology Criteria for Adverse Events v3.0. RESULTS Mean followup was 26 months (range 5 to 61, SD ±13) and mean tumor size was 3.4 cm (range 1.5 to 7.3, SD ±1.2). Major complications occurred in 6 of 91 patients (7%) or after 8 of 92 (9%) procedures. Technically successful ablation was performed in the treatment of 89 of the 93 (96%) tumors or 87 of the 91 patients (96%). Of the 83 tumors with followup longer than 3 months only a single case (1%) of local tumor progression occurred. Overall local control was achieved in 86 of 91 (95%) patients or 88 of 93 (95%) tumors. CONCLUSIONS Midterm followup of percutaneous renal cryoablation shows durability of this treatment method with a low incidence of tumor recurrence beyond 3 months.

Treatment of Neuroendocrine Cancer Metastatic to the Liver: The Role of Ablative Techniques

Carcinoid tumors and islet cell neoplasms are neuroendocrine neoplasms with indolent patterns of growth and association with bizarre hormone syndromes. These tumors behave in a relatively protracted and predictable manner, which allows for multiple therapeutic options. Even in the presence of hepatic metastases, the standard of treatment for neuroendocrine malignancy is surgery, either with curative intent or for tumor cytoreduction, i.e., resection of 90% or more of the tumor volume. Image-guided ablation, as either an adjunct to surgery or a primary treatment modality, can be used to treat neuroendocrine cancer metastatic to the liver. Image-guided ablative techniques, including radiofrequency ablation, alcohol injection, and cryoablation, can be used in selected patients to debulk hepatic tumors and improve patient symptoms. Although long-term follow-up data are not available, the surgical literature indicates that significant ablative debulking may improve patient survival. In this review, we discuss metastatic neuroendocrine disease and its treatment options, especially image-guided ablative techniques.

Inflammatory Pseudotumor of the Spleen Associated With a Clonal Epstein-Barr Virus Genome

We report a case of an inflammatory pseudotumor (IPT) of the spleen occurring in an 81-year-old woman with a history of a monoclonal gammopathy of undetermined significance. Eighteen-month follow-up after splenectomy demonstrated no tumor recurrence or progression of underlying plasma cell disease. Histologic examination of the tumor demonstrated a polymorphic population of inflammatory and epithelioid and spindle cells. Immunophenotyping showed large numbers of T cells, B cells, and polyclonal plasma cells. The epithelioid and spindle cells were positive for vimentin and CD68 but lacked expression of follicular dendritic cell markers and actin. Epstein-Barr virus (EBV) genome was identified in the epithelioid and spindle cell population by in situ hybridization using probes specific for EBV-encoded RNAs (EBER1 and EBER2). Southern blot analysis of digested DNA extracted from the tumor using an EBV-specific probe (XhoI) demonstrated the presence of a single high-intensity band, indicative of EBV monoclonality. While there have been 2 previous reports of hepatic IPTs containing a monoclonal population of EBV-infected tumor cells, this is the first report of such an association occurring in the spleen. The presence of clonal EBV DNA suggests some splenic IPTs may be true neoplasms.

Hypertensive Crisis in a Patient Undergoing Percutaneous Radiofrequency Ablation of an Adrenal Mass Under General Anesthesia

Radiofrequency ablation (RFA) is an effective therapeutic intervention for a variety of neoplastic lesions. Many of these procedures are conducted with patients under general anesthesia. Although RFA is associated with infrequent complications, it is not without risk. Injury to adjacent normal structures is a major concern during RFA of cancerous lesions. Unintended injury to normal adrenal tissue during RFA of adrenal tumors can lead to hypertensive crisis, a potentially catastrophic complication. Hemodynamic consequences of RFA of primary or metastatic adrenal masses have not been reported. We report a case of hypertensive crisis (249/140 mm Hg), tachycardia, and ventricular arrhythmia in an 82-yr-old woman undergoing RFA of renal cell carcinoma metastatic to the adrenal gland. Anesthesiologists should be aware of this potentially catastrophic complication. Direct-acting vasodilators and short-acting &bgr;1-adrenergic antagonists should be immediately available, and intraarterial blood pressure monitoring should be seriously considered when providing care for patients undergoing RFA of an adrenal mass.

Eosinophilic-lymphocytic myocarditis after smallpox vaccination

Smallpox is an eradicated viral disease that has re-emerged as a potential bioterrorism threat. Smallpox vaccination was historically the most effective defence measure against wild smallpox virus. The risk of myopericarditis after vaccination might limit this option. We report a case of biopsy-proven eosinophilic-lymphocytic myocarditis diagnosed in vivo with histological evidence for eosinophil-mediated cardiac myocyte necrosis shortly after smallpox vaccination. Furthermore, we report a beneficial haemodynamic response to high-dose corticosteroids. A better understanding of the aberrant immune mechanism of myocyte injury after smallpox vaccination might improve the risk/benefit assessment for people considering smallpox vaccination and better smallpox vaccines in the future.