Wladyslaw Gedroyc

Hepatocellular carcinoma: current trends in worldwide epidemiology, risk factors, diagnosis and therapeutics

Hepatocellular carcinoma (HCC) is the third most common cause of cancer-related death worldwide and, owing to changes in the prevalence of the two major risk factors, hepatitis B virus and hepatitis C virus, its overall incidence remains alarmingly high in the developing world and is steadily rising across most of the developed world. Early diagnosis remains the key to effective treatment and there have been recent advances in both the diagnosis and therapy of HCC, which have made important impacts on the disease. This review outlines the epidemiological trends, risk factors, diagnostic developments and novel therapeutics for HCC, both in the developing and developed world.

Assessing the Validity of an Abdominal CT Scoring System in the Diagnosis of Encapsulating Peritoneal Sclerosis

BACKGROUND AND OBJECTIVESnEncapsulating peritoneal sclerosis (EPS) is a severe peritoneal fibrotic reaction in patients on long-term peritoneal dialysis (PD). The early clinical features may be nonspecific. The purpose of the study is to assess the reliability and diagnostic utility of abdominal CT scanning in the diagnosis of EPS.nnnDESIGN, SETTING, PARTICIPANTS, & MEASUREMENTSnAbdominopelvic CT scans of 27 patients diagnosed with EPS on clinical and radiologic grounds in our unit from 1997 to 2006 were retrospectively analyzed. In addition, 35 control CT scans were scored: 15 from hemodialysis patients (HD controls) and 20 from patients on PD (PD controls). Scans were anonymized and scored independently by three radiologists.nnnRESULTSnInter-rater agreement was moderate to very good (kappa = 0.40 to 0.75) for peritoneal calcification, bowel distribution, bowel wall thickening, and bowel dilation but poorer for loculation of ascites and peritoneal thickening. There was a strongly significant difference between the total CT scan scores at EPS diagnosis and controls (P < 0.00001). Each individual parameter also showed significant differences between EPS and controls (P < 0.006). Bowel tethering and peritoneal calcification were the most specific parameters, and. loculation was the least discriminatory parameter. Interestingly, prediagnostic scans a median of 1.5 yr before EPS diagnosis were normal or near-normal in 9 of 13 EPS patients.nnnCONCLUSIONSnCT scanning is a valid and reliable adjunct to the diagnosis of EPS but may not be useful as a screening tool, as the prediagnostic scans did not show abnormalities in many patients who subsequently developed EPS.

Focused ultrasound as a local therapy for liver cancer.

Conventional surgical treatments of liver cancer are invasive (including minimally invasive) with a high incidence of new metastasis and poor success, even after multiple resections or ablations. These limitations motivated research into new, less invasive solutions for liver cancer treatment. Focused ultrasound surgery (FUS), or high-intensity focused ultrasound, has been recognized as a noninvasive technology for benign and malignant tumor treatment. Previously, FUS was guided with ultrasound that has limited target definition and monitoring capability of the ablation process. Combining magnetic resonance imaging (MRI) with multiple-element phased-array transducers to create MRI-guided focused ultrasound thermal therapy provides more accurate targeting and real-time temperature monitoring. This treatment is hindered by the ribcage that limits the acoustic windows to the liver and the respiratory motion of the liver. New advances in MRI and transducer design will likely resolve these limitations and make MRI-guided FUS a powerful tool in local liver cancer therapy. This article reviews this technology and advances that can expand its use for cancer treatment in general and liver cancer in particular.

MR‐guided focused ultrasound surgery, present and future

MR-guided focused ultrasound surgery (MRgFUS) is a quickly developing technology with potential applications across a spectrum of indications traditionally within the domain of radiation oncology. Especially for applications where focal treatment is the preferred technique (for example, radiosurgery), MRgFUS has the potential to be a disruptive technology that could shift traditional patterns of care. While currently cleared in the United States for the noninvasive treatment of uterine fibroids and bone metastases, a wide range of clinical trials are currently underway, and the number of publications describing advances in MRgFUS is increasing. However, for MRgFUS to make the transition from a research curiosity to a clinical standard of care, a variety of challenges, technical, financial, clinical, and practical, must be overcome. This installment of the Vision 20∕20 series examines the current status of MRgFUS, focusing on the hurdles the technology faces before it can cross over from a research technique to a standard fixture in the clinic. It then reviews current and near-term technical developments which may overcome these hurdles and allow MRgFUS to break through into clinical practice.

MRI guidance of infra-red laser liver tumour ablations, utilising an open MRI configuration system: technique and early progress

BACKGROUND/AIMSnPrimary and secondary liver tumours are a common clinical problem, with a poor prognosis in most cases. Surgical resection offers the best outcome, but is only appropriate for the minority. Thermal ablation techniques have been described, but the lack of an optimal means of monitoring has limited their use. We undertook a pilot study to assess the feasibility and safety of an integrated MR-guided laser thermoablation technique under local anaesthesia using a real-time colourisation thermal monitoring technique in a newly developed open MR scanner.nnnMETHODSnLiver tumours were punctured after the administration of intravenous Mangafodipir trisodium (MnDPDP) using real-time MR image guidance under local or general anaesthesia, and treated using a water-cooled interstitial fibre and a Nd-YAG laser source. Twenty-seven procedures were performed in 12 patients. Therapy was monitored using a real-time MR colourisation sequence. Thermoablation was followed by a colour change in a region of interest.nnnRESULTSnThermal lesions of mean size 3 cm in diameter were produced with a maximum size of 5 cm. Eight out of 12 patients were discharged the next day with few significant complications. Repeat procedures have been performed in seven of 12 patients. Two patients with lesions of 3 cm diameter have had complete tumour ablation with only one procedure.nnnCONCLUSIONnPercutaneous laser thermoablation for liver tumours performed as an integrated one-step technique in an open configuration MR scanner is described. It can be safely performed under local anaesthesia in the majority of patients, with few side effects. MR control shows the site and size of the evolving thermal lesions, allowing appropriate action to be taken in terms of further burns, time of application and power applied.

The road to clinical use of high-intensity focused ultrasound for liver cancer: technical and clinical consensus

Clinical use of high-intensity focused ultrasound (HIFU) under ultrasound or MR guidance as a non-invasive method for treating tumors is rapidly increasing. Tens of thousands of patients have been treated for uterine fibroid, benign prostate hyperplasia, bone metastases, or prostate cancer. Despite the methods clinical potential, the liver is a particularly challenging organ for HIFU treatment due to the combined effect of respiratory-induced liver motion, partial blocking by the rib cage, and high perfusion/flow. Several technical and clinical solutions have been developed by various groups during the past 15 years to compensate for these problems. A review of current unmet clinical needs is given here, as well as a consensus from a panel of experts about technical and clinical requirements for upcoming pilot and pivotal studies in order to accelerate the development and adoption of focused ultrasound for the treatment of primary and secondary liver cancer.

MRI-guided focused ultrasound (MRgFUS) to treat facet joint osteoarthritis low back pain—case series of an innovative new technique

AbstractObjectiveTo evaluate the safety and efficacy of magnetic resonance-guided focused ultrasound (MRgFUS) to treat facet joint osteoarthritis pain.MethodsPatients with a positive response to facet joint interventions were recruited from Pain and Spinal Clinics. Treatments were performed at the levels of pain according to symptomatology, previous invasive treatment and MRI grading of facet joint osteoarthritis. Both safety and efficacy data were collected. Pain palliation was evaluated using a validated pain numerical rating scale (NRS), Oswestry disability questionnaire (ODQ), Brief Pain Inventory (BPI) and the EuroQol (EQ-5D) health state scoreResultsEighteen patients were treated. There were no major adverse events. At 6/12 we found a reduction in both the NRS (average/worst) pain scores (60.2xa0%/51.2xa0%). This was associated with 45.9xa0% improvement in the ODQ score and 61.9xa0% reduction in the BPI interference score. We observed an improvement in the EuroQol (EQ-5D) health state score based on UK coefficients of +0.379 (0.317 to 0.696).ConclusionsOur phase I observational pilot study has evaluated an innovative new technique that is both non-invasive and radiation free. It is the first description of this procedure in the literature. In all patients the technique was safe, free of complications, effective and well tolerated.Key Points• Magnetic resonance-guided focused ultrasound offers non-invasive therapy for facet joint pain.n • MRgFUS appears to be an effective and safe thermal ablation technique for facet joint pain.n • Real-time image control and thermal feedback minimise complications.n • MRgFUS allows outpatient management of facet joint osteoarthritic low back pain.

Screening for encapsulating peritoneal sclerosis in patients on peritoneal dialysis: role of CT scanning

BACKGROUNDnWe previously validated a scoring system for abdominal/pelvic CT scans in patients with symptomatic encapsulating peritoneal sclerosis (EPS). CT scans of patients with symptomatic EPS were significantly different from control peritoneal dialysis (PD) or haemodialysis patient scans; scans performed before EPS was clinically evident were near normal in 9 of 13 patients. We have now investigated CT scanning as a screening modality in a larger group of patients on long-term PD.nnnMETHODSnPre-diagnostic CT scans performed in 20 patients for routine screening or other indications at least 3 months before EPS developed, and later diagnostic scans when EPS was clinically evident, were scored by three radiologists. The control group included CT scans of 20 PD patients who had not developed EPS (median follow-up 2.25 years). Analysis was by non-parametric tests. CT scores ranged from 0 to 22; > 2.5 was considered abnormal.nnnRESULTSnClinical EPS only developed after transplantation or transfer to HD. Diagnostic scans scored significantly higher than pre-diagnostic or control scans (median scores 9, 2 and 1; P < 0.001), confirming previous work. The pre-EPS diagnosis of 12 asymptomatic patients had a median CT score = 1.75, similar to the control group. Eight patients had had a limited episode of abdominal symptoms (seven required hospitalization), but did not have the clinical picture of EPS; their median CT score was 4.5 (P = 0.0016 cf control group). The time from pre-diagnostic scan to clinical EPS (median 0.82 years) and duration of PD at time of pre-diagnostic scan (median 7.1 years) did not differ significantly between the symptomatic and asymptomatic groups.nnnCONCLUSIONSnCT screening of asymptomatic PD patients is not indicated; EPS may occur within a year or less of a normal CT scan. Abdominal symptoms in long-term PD patients can be associated with CT scan abnormalities; these patients are at increased risk of EPS after stopping PD.

Midfoot and Hindfoot Bone Marrow Edema Identified By Magnetic Resonance Imaging in Feet of Subjects With Diabetes and Neuropathic Ulceration Is Common but of Unknown Clinical Significance

OBJECTIVE We conducted a retrospective cohort study assessing the prevalence and clinical and radiological outcome of remote areas of bone marrow edema on magnetic resonance imaging (MRI) in the feet of subjects with diabetes and neuropathic foot ulceration. RESEARCH DESIGN AND METHODS MRIs performed over 6 years looking for osteomyelitis associated with neuropathic lesions were assessed for remote areas of signal change. RESULTS Seventy MRI studies were assessed. Remote areas of signal change were present in 21 (30%) subjects, involved midfoot or hindfoot in 20 subjects, were associated with younger age and renal replacement therapy, and did not predict future Charcot neuroarthropathy or infection at that site. Repeat MRIs in 11 subjects with such areas found that none had progressed, six had improved, and two had resolved; in 29 subjects without such areas, five had developed new areas. CONCLUSIONS Bone marrow edema in the midfoot and hindfoot of subjects with diabetes and neuropathic lesions is common, often transient, and of unknown significance.

Feasibility of abdomino-pelvic T1-weighted real-time thermal mapping of laser ablation.

To prove the hypothesis that T1‐weighted (T1W) thermal mapping is reliable and achievable in magnetic resonance (MR)‐guided laser tumor ablation.