Natalie Lucchina

Microwave ablation of pancreatic head cancer: safety and efficacy.

PURPOSE To evaluate the safety and efficacy of percutaneous microwave (MW) ablation treatment in locally advanced, nonresectable, nonmetastatic pancreatic head cancer. MATERIALS AND METHODS Ten patients with pancreatic head cancer treated with percutaneous (n = 5) or laparotomic (n = 5) MW ablation were retrospectively reviewed. The MW generator used (45 W at 915 MHz) was connected by coaxial cable to 14-gauge straight MW antennas with a 3.7- or 2-cm radiating section. One or two antennae were used, with an ablation time of 10 minutes. Ultrasonographic (US) and combined US/cone-beam computed tomographic (CT) guidance were used in five patients each. Follow-up was performed by CT after 1, 3, 6, and, when possible, 12 months. Tumor response was assessed per Response Evaluation Criteria In Solid Tumors (version 1.1) and Choi criteria. The feasibility, safety, and major and minor complications associated with quality of life (QOL) were recorded prospectively. RESULTS The procedure was feasible in all patients (100%). One late major complication was observed in one patient, and no visceral injury was detected. No patient had further surgery, and all minor complications resolved during the hospital stay. An improvement in QOL was observed in all patients despite a tendency to return to preoperative levels in the months following the procedure, without the influence of minor complications. No repeat treatment was performed. CONCLUSIONS Despite the small number of patients, the present results can be considered encouraging, showing that MW ablation is a feasible approach in the palliative treatment of pancreatic tumors.

Systematic review of minimally invasive ablation treatment for locally advanced pancreatic cancer.

Unresectable locally advanced pancreatic cancer with or without metastatic disease is associated with a very poor prognosis. Ablation techniques are based on direct application of chemical, thermal, or electrical energy to a tumor, which leads to cellular necrosis. Initial studies about ablation therapies of the pancreas were associated with significant morbidity and mortality, which limited widespread adoption. Modifications to the various applications, in particular combining the techniques with high-quality imaging and intra-operative approach has enabled real-time treatment monitoring and significant improvements in safety. Inoperable cases of pancreatic cancer have been treated by various ablation techniques in the last few years with promising results. The purpose of this review is to present the current status of local ablative therapies in the treatment of pancreatic advanced tumor.

Microwave Ablation with Percutaneous Approach for the Treatment of Pancreatic Adenocarcinoma

Pancreatic adenocarcinoma, characterized by a late presentation and by high aggressiveness, is one of the most lethal human cancers and currently the fifth most common cause of cancer-related death in men [1]. Only 10% of the tumors are confined to the pancreas at the time of presentation, 30–40% are locally advanced, and 50% have distant metastases [1, 2]. Only approximately 20% of pancreatic cancers are found to be resectable at the time of presentation. Surgical resection is the only potentially curative treatment for pancreatic cancer [2]. Some palliative therapeutic modalities have been applied in treatment of unresectable locally advanced pancreatic carcinoma, such as chemotherapy and chemoradiation [3]. In a few patients, thermal ablative techniques, such as radiofrequency ablation (RFA) and microwave ablation (MWA), have been reported, especially in association with surgery [4, 5]. Date RS [6] reviewed the results of local ablative therapies for the treatment of pancreatic cancer; photodynamic therapy (PDT), high-intensity ultrasound (HIFU), cryoablation, and RFA may have role in ablation of pancreatic tumors. Wu et al. [7] reported encouraging results on the feasibility of HIFU ablation of pancreas tumor, but they excluded patients with carcinoma located in the head to avoid damage of the biliary duct. Photodynamic therapy has major disadvantages of organizational and technical difficulties in setting up the treatments and potential side effects, such as skin photosensitivity reaction [8]. Matsui et al. [9] performed laparotomy and radiofrequency heating in 20 patients with unresectable pancreatic carcinomas. They have reported an intraperitoneal abscess in one patient who died of septic shock. Potential benefits of these techniques include treatment of patients who are not surgical candidates and reduced morbidity compared with surgery. Ablation with microwave has several intrinsic advantages over RFA, including the capability to generate very high tissue temperature, less intraprocedural pain, larger coagulation zones, less sensitivity to tissue type and charring, improved performance near blood vessels, and no requirement of ground pads [10–12]. Recently, this technique has been proposed in different organs, such as liver, lung, and kidney [10]. However, only few cases regarding the use of MWA in pancreatic cancer have been published and they were performed under laparotomy [5]. To the best of our knowledge, our case G. Carrafiello (&) A. M. Ierardi F. Piacentino N. Lucchina C. Fugazzola Interventional Radiology, Department of Radiology, Insubria University, Viale Borri, 57, 21100 Varese, Italy e-mail: gcarraf@tin.it

Current role of microwave ablation in the treatment of small hepatocellular carcinomas

Percutaneous radiofrequency ablation (RFA) can be as effective as surgical resection in terms of overall survival and recurrence-free survival rates in patients with small hepatocellular carcinoma (HCC). Effectiveness of RFA is adversely influenced by heat-sink effect. Other ablative therapies could be considered for larger tumors or for tumors located near the vessels. In this regard, recent improvements in microwave energy delivery systems seem to open interesting perspectives to percutaneous ablation, which could become the ablation technique of choice in the near future. Microwave ablation (MWA) has the advantages of possessing a higher thermal efficiency. It has high efficacy in coagulating blood vessels and is a relatively fast procedure. The time required for ablation is short and the shape of necrosis is elliptical with the older systems and spherical with the new one. There is no heat-sink effect and it can be used to ablate tumors adjacent to major vessels. These factors yield a large ablation volume, and result in good local control and fewer complications. This review highlights the most relevant updates on MWA in the treatment of small (<3 cm) HCC. Furthermore, we discuss the possibility of MWA as the first ablative choice, at least in selected cases.

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 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.

Point Shear Wave Elastography of the Spleen: Its Role in Patients with Portal Hypertension

The goals of the study described here were to evaluate the feasibility and reproducibility of measuring spleen stiffness (SS) using point shear wave elastography in a series of cirrhotic patients and to investigate whether SS, liver stiffness (LS) and other non-invasive parameters are correlated with the presence of esophagogastric varices (EVs). Fifty-four cirrhotic patients with low-grade EVs or without EVs at esophago-gastro-duodenoscopy were enrolled. They underwent abdominal ultrasound and Doppler ultrasound of hepatic vessels simultaneously with p-SWE of the liver and spleen. In 42 patients, the accuracy of LS and SS, as well as of platelet count and spleen longitudinal diameter, in predicting the presence of EVs was evaluated. The technical success was 90.74% for LS (49/54 patients) and 77.78% for SS (42/54 patients). Inter-observer agreement for SS measurement was high. Both LS and SS correlated with esophago-gastro-duodenoscopy: LS had the highest accuracy in predicting the presence of EVs (area under the receiver operating characteristic curve [AUROC] = 0.913); SS had the lowest accuracy (AUROC = 0.675); platelet count and spleen diameter had intermediate accuracy (AUROC = 0.731 and 0.729, respectively). SS did not have an advantage over LS in predicting low-grade EVs and cannot be proposed as a useful tool in the diagnostic process of cirrhotic patients who require screening esophago-gastro-duodenoscopy.

Ability of specific and nonspecific signs of multidetector computed tomography (MDCT) in the diagnosis of blunt surgically important bowel and mesenteric injuries

PurposeTo determine the accuracy of MDCT in the evaluation of blunt surgically relevant bowel and/or mesenteric injuries (BMIs) using single specific CT signs together with specific pairs of nonspecific signs.MethodsFifty-four patients examined with MDCT were divided into two groups: a ‘surgical’ group of 20 patients—which underwent surgery for blunt BMIs—and a control group of 34 ‘nonsurgical’ trauma patients. Two radiologists with different experience performed a double-blind retrospective evaluation of the images, classifying the patients in the two groups by using only single specific signs; then, the images were reviewed in consensus with a third radiologist and sensitivity and specificity were calculated. Subsequently, the frequency of every single sign and of every possible combination of nonspecific signs in the two groups was registered, to find combinations present only in the surgical group; sensitivity and specificity were calculated by using even those specific combinations.ResultsAt the first consensual evaluation, sensitivity and specificity were 75 and 100%, respectively. Two combinations of nonspecific signs (focal wall thickening + extraluminal air; focal wall thickening + seat belt sign) were found only in surgical patients that did not present any single specific sign: Sensitivity calculated adding those two combinations was 95%, without a decrease in specificity.ConclusionsMDCT is an accurate technique in the evaluation of blunt surgically relevant BMIs. The single specific CT signs were sufficient for the diagnosis in only 75% of the cases; adding the two specific combinations allowed an increase in sensitivity of 20%.

Interventional Radiology in the Treatment of Abscess Collections

Renal and perinephric abscess can result in significant morbidity and mortality with complications including sepsis, renal failure, and fistula formation.

Injuries of the Limbs in Polytrauma: Upper and Lower Limbs

Extremity injuries are the second most common traumatic injuries after head injuries and account until 80% of all cases of vascular trauma. Peripheral injuries are usually not immediately lethal, whether due to penetrating or blunt injuries; nevertheless, a prompt identification of the injuries is crucial for a correct management.