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Background Prophylactic image-guided procedures performed by interventional radiologists for impending pathologic fractures are becoming more pertinent, as patients with metastatic cancer have extended overall survival because of advanced therapies. Purpose To evaluate the efficacy, safety, and palliative durability of collimated-beam CT-guided percutaneous fixation with internal cemented screws (FICS) for impending pathologic fractures of the femoral neck. Materials and Methods This single-institute retrospective study examined all patients with metastatic cancer treated between February 2010 and October 2019 with collimated-beam CT-guided percutaneous FICS procedures for preventive consolidation of impending femoral neck pathologic fractures. The short-term palliative efficacy was assessed through comparison of visual analog scale (VAS) scores before and 1 month after FICS. A review of cross-section imaging and clinic reports identified any procedural complications. Long-term consolidation efficacy was defined as the absence of any screw dislodgement or development of a pathologic fracture at completion of the study. The Wilcoxon test was used for the mean comparison of paired nonparametric variables. Results Sixty-one consecutive patients (mean age, 59 years ± 11 [standard deviation]; 35 women) underwent preventive FICS for consolidation of impending pathologic femoral neck fracture with a mean follow-up of 533 days ± 689. Two patients died of cancer within the first month. Complications were limited to three self-resolving hematomas. The mean VAS score decreased 1 month after FICS from 4.2 ± 3.2 to 1.8 ± 2.0 (P < .001). The long-term consolidation efficacy was 92% (54 of 59 patients), with three of 59 patients (5%) subsequently developing fractures despite FICS and an additional two of 59 patients (3%) with durable FICS undergoing definitive total hip arthroplasty surgery because of local tumor progression. Conclusion Percutaneous fixation with internal cemented screws as performed by the interventional radiologist is a safe nonsurgical treatment that provides an effective palliative result and durable prevention for impending pathologic fractures of the femoral neck. © RSNA, 2020 Online supplemental material is available for this article.

Background Percutaneous CT-guided biopsy of lung nodules is an established method with high diagnostic accuracy but a high rate of pneumothorax and chest tube insertion compared with endobronchial methods. Purpose To investigate the effect of a protocol combining patient positioning biopsy-side down, needle removal during expiration, autologous blood patch sealing, rapid rollover, and pleural patching (PEARL) on complication rate after percutaneous CT-guided lung biopsy, especially chest tube insertion. Materials and Methods In a secondary analysis of both prospectively and retrospectively acquired data from December 2019 to November 2020, consecutive participants underwent biopsy with use of the PEARL protocol (prospective data) and were compared with patients who underwent biopsy at the same tertiary cancer center according to the standard method without any additional techniques (controls, retrospective data). Patient demographics, lesion characteristics, intraprocedural data, complications, and histologic results were recorded and compared. Results One hundred patients in the control group (mean age ± standard deviation, 63 years ± 12; 61 men) and 100 participants in the PEARL group (mean age, 64 years ± 12; 48 men) were evaluated. No differences were found in patient and lesion characteristics. The emphysema rate was 47 of 100 patients (47%) in both groups. The rate of pneumothorax was 37 of 100 patients (37%) in the control group versus 16 of 100 (16%) in the PEARL group (

Purpose To evaluate the safety and efficacy of palliative treatment of patients with pathologic pelvic by using fluoroscopy and cone-beam CT needle guidance software to perform percutaneous fixation by internal cemented screw (FICS). Materials and Methods This single-center study involved retrospective analysis of 100 consecutive patients with cancer with pathologic pelvic fractures managed with percutaneous FICS. Image guidance was performed with fluoroscopy and cone-beam CT needle guidance software. Pain palliative outcomes and opioid use after FICS were compared by means of paired-sample t test. Results A total of 107 percutaneous FICS procedures were performed from 2010 to 2017 to palliate 141 pathologic fractures in 100 patients (mean age, 65.0 years ± 17.6 [standard deviation; female age, 66.3 years ± 18.0; mean, 63.7 years ± 17.2]). Of 107 procedures, 104 (97.2%) were technically successful, with mean postprocedure hospitalization of 2 days ± 3. Complications occurred in 14 patients: focal pain at procedure site for longer than 48 hours (n = 5), hematoma (n = 3), progressive fracture despite fixation (n = 2), infection (n = 1), tumor track seeding (n = 1), and screw displacement (n = 2). In the 88 patients who completed early follow-up, mean numeric rating scale pain score was significantly improved at 6 weeks from 6.1 ± 2.5 to 2.1 ± 3.0 (P < .001). Opioid use was reduced at 6 weeks (preprocedure vs postprocedure, 91.3 g ± 121 vs 64.6 g ± 124, respectively; P = .04). Conclusion Fluoroscopy and cone-beam CT-guided percutaneous fixation of pathologic pelvis fractures by internal cemented screw is a safe and effective approach that can reduce pain and opioid use. © RSNA, 2018.

Metastatic liver disease is the most common cause of death in cancer patients. Complete surgical resection is currently considered the only curative treatment, with only about 25% of patients being amenable to surgery. Therefore, a variety of interventional oncologic techniques have been developed for treating secondary liver malignancies. The aim of these therapies is either to allow patients with unresectable tumors to become surgical candidates, provide curative treatment options in nonsurgical candidates, or improve survival in a palliative or even curative approach. Among these interventional therapies are transcatheter therapies such as portal vein embolization, hepatic artery infusion chemotherapy, transarterial chemoembolization, and radioembolization, as well as interstitial techniques, particularly radiofrequency ablation as the most commonly applied technique. The rationale, application and clinical results of each of these techniques are reviewed on the basis of the current literature. Future prospects such as gene therapy and immunotherapy are introduced.

To compare fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) combined with computed tomography (PET/CT) and chest CT in the evaluation of the effectiveness of lung radiofrequency (RF) ablation.Institutional review board approved the study, and all patients gave written informed consent. Thirty-four patients (22 men and 12 women; mean age, 64 years) planned to undergo lung RF ablation were prospectively included and underwent FDG PET/CT and chest CT before (pre-RF ablation PET) and 24 hours, 1 month, and 3 months after RF ablation. Persistent equivocal findings up to 3 months were followed up.Pre-RF ablation PET led to changes in the treatment strategy in nine patients (26%) by depicting unexpected metastases. Two patients without FDG uptake in lesions to be treated were excluded. Overall, 28 patients (46 lesions: five primary cancer, 41 metastases) were treated and followed up. Within 3 months after RF ablation, incomplete treatment was diagnosed in four of 28 patients (14%, three at 1 month and one at 3 months). Findings of FDG PET/CT were true-positive in four, false-positive in one, and true-negative in 23 patients. Findings of chest CT were true-positive in one, false-positive in one, false-negative in three, and true-negative in 23 patients. Inflammatory FDG uptake in mediastinal lymph nodes and at the needle path puncture site used for RF ablation was observed in 15%, 21%, and 15% of patients and in 19%, 11%, and 15% of patients at 24 hours, 1 month, and 3 months, respectively.FDG PET/CT can be used for the evaluation of the effectiveness of lung RF ablation. Inflammatory FDG uptake in mediastinal lymph nodes or at the needle path site used for RF ablation may occur.

To prospectively evaluate the technical feasibility, effectiveness, and complications of percutaneous radiofrequency (RF) ablation for hepatic malignancies during temporary percutaneous balloon occlusion (PBO) of a large hepatic or portal vein.During a 4-year period, RF ablation was performed in 201 patients (106 men, 95 women; age range, 41-88 years) with 233 liver tumors. Institutional review board approval was obtained to attempt RF ablation during PBO for 18 tumors that were larger than 35 mm (mean, 43 mm +/- 7.6 [standard deviation]; range, 36-60 mm) and did not abut a portal or hepatic vein 4 mm in diameter or larger (group 1), 58 tumors 35 mm or smaller (mean, 23 mm +/- 7.3; range, 12-35 mm) that abutted a large vessel (group 2), and 20 tumors that were both larger than 35 mm (mean, 42 mm +/- 5.7; range, 38-50 mm) and abutted a large vessel (group 3). RF ablation without PBO was performed for 137 tumors 35 mm or smaller (mean, 22 mm +/- 6.8; range, 9-35 mm) and remote from large vessels (group 4). Rate of local tumor progression was estimated with the Kaplan-Meier method, and tumor progression-free rates were compared between the four groups with the log-rank test. Complications were compared by using the Fisher exact test between the four groups and between the two RF devices used.PBO was achieved in 94 of 96 attempts (98%), including 64 of 64 hepatic veins and 30 of 32 portal branches. After a mean follow-up of 18 months +/- 9, 10 tumors in eight patients were lost to follow-up. Local tumor progression was observed in six (40%) of 15 tumors in group 1, in six (11%) of 56 tumors in group 2, in eight (40%) of 20 tumors in group 3, and in 12 (9%) of 130 tumors in group 4. Combined analysis of tumor size and the use of PBO showed that size was the only prognostic factor for tumor progression, with a hazard ratio of 4.9 (95% confidence interval: 2.4, 9.9) (P.001). There were no differences between groups 2 and 4. Asymptomatic, transient postprocedure venous thrombosis was seen in nine of 94 RF ablations with PBO, while occlusion of one permanent portal branch induced segmental liver atrophy. There were no differences in rates of complications (5% and 6% for RF ablation with and that without PBO, respectively).RF ablation with PBO provides tumor control for tumors smaller than 35 mm in diameter that abut vessels 4 mm or larger, equivalent to tumor control of the same-size tumors away from vessels. PBO does not seem to affect the results of RF ablation for tumors 35 mm or larger.

Purpose: To prospectively compare single- and multisection computed tomographic (CT) perfusion for tumor blood flow determination in an animal model. Materials and Methods: All animal protocols and experiments were approved by the institutional animal care and use committee before the study was initiated. R3230 mammary adenocarcinoma was implanted in 11 rats. Tumors (18–20 mm) were scanned with dynamic 16-section CT at baseline and after administration of arsenic trioxide, which is known to cause acute reduction in blood flow. The concentration of arsenic was titrated (0–6 mg of arsenic per kilogram of body weight) to achieve a defined blood flow reduction (0%–75%) from baseline levels at 60 minutes, as determined with correlative laser Doppler flowmetry. The mean blood flow was calculated for each of four 5-mm sections that covered the entire tumor, as well as for the entire tumor after multiple sections were processed. Measurements obtained with both methods were correlated with laser Doppler flowmetry ...

After institutional review board approval, informed consent was obtained from six patients (four men and two women, aged 47-74 years) with a total of six tumors of the liver dome. These patients were treated by means of radiofrequency (RF) ablation with computed tomographic (CT) guidance and a transthoracic approach. With use of general anesthesia, a right pneumothorax was induced by means of manual injection of air until the route allowing access to the tumor was cleared of all lung parenchyma. Then RF ablation was performed with transthoracic extrapulmonary transdiaphragmatic access. After retrieval of the RF electrode, the pneumothorax was fully aspirated. All procedures were successfully performed without complications. Artificially induced pneumothorax appears useful and safe for CT-guided RF ablation of liver dome tumors, although this experience was minimal, with only six patients treated.

To retrospectively assess the frequency of adverse events related to percutaneous preoperative portal vein embolization (PPVE).Institutional review board did not require its approval or patient informed consent for this study. The adverse events that occurred during PPVE or until planned hepatic surgery was performed or cancelled were retrospectively obtained from clinical, imaging, and laboratory data files in 188 patients (109 male and 79 female patients; mean age, 60 years; range, 16-78 years). Liver resection was planned for metastases (n = 137), hepatocarcinoma (n = 31), cholangiocarcinoma (n = 15), fibrolamellar hepatoma (n = 1), and benign disease (n = 4). PPVE was performed with a single-lumen 5-F catheter and a contralateral approach with n-butyl cyanoacrylate mixed with iodized oil as the main embolic agent. The rate of complications in patients with cirrhosis was compared with that in patients without cirrhosis by using the chi(2) test.Adverse events occurred in 24 (12.8%) of 188 patients, including 12 complications and 12 incidental imaging findings. Complications included thrombosis of the portal vein feeding the future remnant liver (n = 1); migration of emboli in the portal vein feeding the future remnant liver, which necessitated angioplasty (n = 2); hemoperitoneum (n = 1); rupture of a metastasis in the gallbladder (n = 1); transitory hemobilia (n = 1); and transient liver failure (n = 6). Incidental findings were migration of small emboli in nontargeted portal branches (n = 10) and subcapsular hematoma (n = 2). Among the 187 patients in whom PPVE was technically successful, there was a significant difference (P.001) between the occurrence of liver failure after PPVE in patients with cirrhosis (five of 30) and those without (one of 157). Sixteen liver resections were cancelled due to cancer progression (n = 12), insufficient hypertrophy of the nonembolized liver (n = 3), and complete portal thrombosis (n = 1).PPVE is a safe adjuvant technique for hypertrophy of the initially insufficient liver reserve. Post-PPVE transient liver failure is more common in patients with cirrhosis than in those without cirrhosis.

To evaluate the feasibility, efficacy, and tolerance of pulmonary radiofrequency (RF) ablation for the treatment of lung tumors in patients with a single lung.This was a retrospective study from four institutions, with waiver of institutional review board approval and of informed consent. From July 2003 to March 2009, 15 single-lung patients (nine men and six women; mean age, 64 years; age range, 42-82 years) with one to three lung tumors underwent 16 sessions of RF ablation. One patient underwent two sessions due to occurrence of new tumors. Eleven patients had primary lung cancer and four patients had metastases. The previous pneumonectomy was performed for the treatment of primary or secondary lung tumors. Twenty-one tumors measuring 4-37 mm (mean, 15.5 mm ± 8 [standard deviation]) were treated. All procedures were performed by using general anesthesia with intubation. Electrodes were expandable in 13 procedures and straight in three. The efficacy was evaluated with computed tomography (CT) or positron emission tomography (PET)/CT, performed 3, 6, 12, and 18 months and 2 years after treatment. The median follow-up was 17.6 months, with seven patients being followed at 1 year and three being followed at 2 years. Treatment tolerance was evaluated from results of clinical examination, follow-up CT, and CT performed immediately after completion of RF ablation.No procedural deaths occurred. Procedural complications observed at CT during RF ablation were mild parenchymal hemorrhages (n = 5; 31%). All pneumothoraces (n = 6; 37%) resolved after chest tube placement. Postprocedural complications included one case of pulmonary infection and two cases of limited hemoptysis. Complete tumor ablation was obtained in all RF sessions but one (15 of 16; 95%). Overall survival rate was 71.4% (95% confidence interval [CI]: 36%, 92%) at 2 years; cancer-specific survival was 100% at 2 years. The tumor-free survival was 58.7% (95% CI: 32%, 81%) at 1 year and 19.6% (95% CI: 4%, 58%) at 2 years.RF ablation appears to be a reasonable and safe option in patients with a single lung.

To prospectively compare single- and multisection computed tomographic (CT) perfusion for tumor blood flow determination in an animal model.All animal protocols and experiments were approved by the institutional animal care and use committee before the study was initiated. R3230 mammary adenocarcinoma was implanted in 11 rats. Tumors (18-20 mm) were scanned with dynamic 16-section CT at baseline and after administration of arsenic trioxide, which is known to cause acute reduction in blood flow. The concentration of arsenic was titrated (0-6 mg of arsenic per kilogram of body weight) to achieve a defined blood flow reduction (0%-75%) from baseline levels at 60 minutes, as determined with correlative laser Doppler flowmetry. The mean blood flow was calculated for each of four 5-mm sections that covered the entire tumor, as well as for the entire tumor after multiple sections were processed. Measurements obtained with both methods were correlated with laser Doppler flowmetry measurements. Interobserver agreement was determined for two blinded radiologists, who calculated the percentage of blood flow reduction for the "most representative" single sections at baseline and after arsenic administration. These results were compared with the interobserver variability of the same radiologists obtained by summing blood flow changes for the entire tumor volume.Overall correlations for acute blood flow reduction were demonstrated between laser Doppler flowmetry and the two CT perfusion approaches (single-section CT, r=0.85 and r(2)=0.73; multisection CT, r=0.93 and r(2)=0.87; pooled data, P=.01). CT perfusion disclosed marked heterogeneity of blood flow, with variations of 36% +/- 13 between adjacent 5-mm sections. Given these marked differences, interobserver agreement was much lower for single-section CT (standard deviation, 0.22) than for multisection CT (standard deviation, 0.10; P=.01).Multisection CT perfusion techniques may provide an accurate and more reproducible method of tumor perfusion surveillance than comparison of single representative tumor sections.

To prospectively evaluate the local efficacy of radiofrequency (RF) ablation of lung neoplasms, with a minimum follow-up period of 1 year.Sixty patients (34 men and 26 women; age range, 27-81 years; mean age, 66 years) with 100 lung tumors gave written informed consent to be enrolled in a prospective study that was approved by the local ethics committee. There were five or fewer tumors per patient, each with a diameter of less than 40 mm (mean +/- standard deviation, 17 mm +/- 10). RF ablation was performed in tumors by using computed tomographic (CT) guidance. Follow-up CT studies were obtained within 48 hours after treatment and at 2, 4, 6, 9, and 12 months thereafter to evaluate treatment outcome and complications. Lung spirometry measurements were obtained before and 4 weeks after RF ablation.Ninety-seven of 100 targeted tumors were treated and required 163 RF ablations (1.68 per tumor), each lasting 14 minutes +/- 8, delivered during 74 procedures. The 18-month estimated rate of incomplete local treatment at CT was 7% (95% confidence interval: 3%, 14%) per tumor and 12% (95% confidence interval: 5%, 23%) per patient. An ablation area at least four times larger than the initial tumor was predictive of complete ablation treatment (P = .02). There was a trend toward better efficacy for tumors smaller than 2 cm in diameter (P = .066). Overall survival and lung disease-free survival at 18 months were 71% and 34%, respectively. The main adverse event was a pneumothorax, which occurred in 54% of procedures, but a chest tube was required in only 9% of the procedures. No modification of respiratory function was found when spirometry measurements obtained before and within 2 months after RF ablation were compared (P = .51).RF ablation has a high local efficacy and is well tolerated.

To describe the appearance of hepatic tumors treated with radio-frequency (RF) ablation on computed tomographic (CT) and magnetic resonance (MR) images and the pattern of residual tumor at the site of RF ablation and to assess prospectively the sensitivity, specificity, and positive and negative predictive CT and MR imaging values in the evaluation of RF treatment.Thirty-one patients with 50 tumors (nine hepatocellular carcinomas and 41 metastases) treated with RF ablation underwent CT and MR imaging on the same day at 2, 4, and 6 months; CT was performed every 3 months thereafter. CT and MR findings were interpreted separately and prospectively by two reviewers with consensus. For both imaging techniques, appearance of the treated area, treatment efficacy, and complications were assessed at each time. Sensitivity and specificity were determined by using the McNemar test.After a mean follow-up of 19 months, nine tumors showed local regrowth. At 2 months, MR imaging depicted more local regrowths (eight of nine; sensitivity, 89%) than did CT (four of nine; sensitivity, 44%) but without significant differences (P =.12). In two cases, only T2-weighted imaging depicted local regrowth. All nine lesions became conspicuous at 4-month follow-up with both techniques. At 2 months, thin peripheral rim enhancement and arterioportal shunting were found in 24% and 12%, respectively, of the treated tumors. These findings disappeared thereafter and are not linked to tumor regrowth.Despite the small number of patients, CT and MR imaging may depicted all local regrowth at 4 months or sooner. MR imaging may have an edge over CT in the early detection of local regrowth.