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To evaluate the effectiveness of noninvasive magnetic resonance (MR) imaging-guided focused ultrasonographic (US) ablation of breast carcinomas.Before undergoing tumor resection, 12 patients with invasive breast carcinomas were treated with MR imaging-guided focused US ablation consisting of multiple sonications of targeted points that were monitored with temperature-sensitive MR imaging. The patients were treated with either one of two focused US systems. The effectiveness of the treatment was determined at histopathologic analysis of the resected mass that was performed to determine the volumes of necrosed and residual tumor. Complications resulting from the procedure were assessed by means of questionnaires, medical examinations, and MR image analysis.US ablation was well tolerated by the patients, and with the exception of minor skin burns in two patients, no complications occurred. Histopathologic analysis of resected tumor sections enabled quantification of the amount of necrosed and residual tumor and visualization of the surrounding hemorrhage. In three patients treated with one of the US systems, a mean of 46.7% of the tumor was within the targeted zone and a mean of 43.3% of the cancer tissue was necrosed. In nine patients treated with the other US system, a mean of 95.6% of the tumor was within the targeted zone and a mean of 88.3% of the cancer tissue was necrosed. Residual tumor was identified predominantly at the periphery of the tumor mass; this indicated the need to increase the total targeted area (ie, with an increased number of sonications).Thermal coagulation of small breast tumors by means of MR imaging-guided focused US appears to be a promising noninvasive ablation procedure.

To determine the accuracy of helical computed tomography (CT) with CT angiography in identifying vascular invasion by periampullary neoplasms and to assess the added value of CT angiography.Sixty-nine patients suspected of having periampullary neoplasms were examined. Images from dual phase helical CT with CT angiography were compared with surgical findings in 36 patients. Arterial and venous invasion were assessed separately. Accuracy, positive predictive value (PPV), and negative predictive value (NPV) were determined for CT alone and for CT supplemented with CT angiography.The accuracy, PPV, and NPV of helical CT with CT angiography in identifying venous invasion was 92% (33 of 36 patients), 86% (12 of 14 patients), and 95% (21 of 22 patients), respectively. When transverse CT images alone were analyzed, accuracy decreased to 69% (25 of 36 patients) (P =.005); PPV and NPV were 63% (five of eight patients) and 71% (20 of 28 patients), respectively. When identifying arterial invasion, the accuracy of CT with CT angiography and of CT alone was 86% (31 of 36 patients). PPV and NPV also were identical at 71% (five of seven patients) and 90% (26 of 29 patients), respectively.CT angiography significantly increases the ability to identify venous invasion when compared with CT alone but does not improve detection of arterial invasion.

PURPOSE To assess if the learning process associated with computed tomography fluoroscopy (CTF) technology influences procedure and fluoroscopy times for percutaneous biopsy procedures. MATERIALS AND METHODS Prospective analysis of the initial 250 consecutive patients who underwent percutaneous biopsy with use of a CT scanner equipped with rapid image reconstruction and fluoroscopic capabilities in a 24-month period. All procedures were performed with both continuous and spot fluoroscopic technique, with typical radiation parameters of 50 mA, 120 kV, and a 10-mmslice thickness. The procedures were all performed by a single experienced interventional radiologist to limit the variables of physician expertise, interventional materials used, and biopsy approach. The subject group was divided into five equal consecutive groups of 50 patients. In each subgroup, the authors recorded mean lesion size, success, and complication rates, as well as mean procedure and fluoroscopy times. RESULTS The five subgroups were similar patient populations as documented by the absence of statistically significant differences when comparing mean lesion size, procedure success, and complication rates ( P > .05; ANOVA test). A statistically significant decrease in mean fluoroscopy (groups 1–5: 50.26 vs 45.24 vs 33.86 vs 32.68 vs 25.8 sec/patient) and mean procedure times (groups 1–5: 30.08 vs 27.9 vs 26.34 vs 25.6 vs 21.6 min/patient) was recorded between the patient subgroups ( P CONCLUSION The learning process associated with CTF technology impacts procedure parameters by decreasing both mean procedure and fluoroscopy times, thereby increasing patient turnover and decreasing radiation exposure to the patient and the operator.

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 .

Whipple's operation consists of resection of the pancreatic head and duodenum, followed by pancreaticojejunostomy, choledochojejunostomy, and gastrojejunostomy or duodenojejunostomy. Indications include neoplasms of the periampullary region, symptomatic chronic pancreatitis, and, occasionally, trauma CT is useful in diagnosing postoperative complications and in detecting disease recurrence during long-term follow-up. This complex surgical procedure causes alterations of the normal anatomy, which may lead to difficulty interpreting images. Familiarity with the appearance of postoperative changes and common complications and with patterns of disease recurrence is a prerequisite to accurate interpretation of CT scans in these patients.

Thirty healthy volunteers and 12 liver allograft recipients (two with cirrhotic changes seen at microscopy) were given a standard meal. Doppler sonography of the right and left hepatic arteries, the superior mesenteric artery, and the portal vein was performed. The change in hepatic arterial resistance was evaluated with the resistive index (RI). After the standard meal, portal venous flow increased in both the healthy volunteers and allograft recipients (more so in the latter group). Superior mesenteric arterial RI decreased in all subjects. A postprandial increase in hepatic arterial RI, likely reflecting constriction of the hepatic artery, was seen in both groups. It was absent in the two patients with recurrent transplant cirrhosis. These results show the importance of examining hepatic arterial flow in the fasting subject, since high resistance after a meal may be falsely interpreted as a sign of disease. Absence of a postprandial change in resistance of the hepatic artery could signal abnormal liver function.

Three patients with portal venous gas (one with radiographic and computed tomographic findings) had similar sonographic and Doppler patterns in the portal vein (PV). These patterns consisted of hyperechogenic foci moving within the lumen of the PV, producing sharp bidirectional spikes superimposed on the usual Doppler tracing of the PV. An injection of 0.25-0.50 cm3 of air, oxygen, nitrogen, and carbon dioxide into the jejunal vein of nine dogs yielded identical portal venous sonographic and Doppler patterns. In addition, the liver parenchyma of the dogs became hyperechogenic after the injection of gas. Gas in the PV is accompanied by the following signs: echogenic, moving foci within the lumen of the PV; sharp spikes on Doppler spectral display; and hyperechogenic foci within the liver parenchyma.

To evaluate the safety and initial efficacy of magnetic resonance (MR) imaging-guided focused ultrasound for the palliation of pain caused by bone metastases in patients in whom standard available treatments had been ineffective or not feasible.Informed consent was obtained in 11 patients (seven women, four men; average age, 58.6 years) with pain related to non-weight-bearing bone metastases who were subsequently treated with MR imaging-guided focused ultrasound in this research and ethics board-approved study. Efficacy was evaluated by changes in visual analog scale (VAS) scores, in pain medication usage, and in quality of life. Safety of the device was evaluated by recording incidence and severity of treatment-related adverse events up to 3 months after treatment at physical examination and follow-up imaging. Follow-up imaging included contrast material-enhanced MR imaging and unenhanced computed tomography (CT) 1 month after treatment and contrast-enhanced MR imaging 3 months after treatment. Imaging studies were assessed for changes in tumor imaging characteristics and any adverse events associated with MR imaging-guided focused ultrasound treatment.Twelve lesions were treated in 11 patients. All patients reported progressive decrease in pain in treated regions and reduction in pain medication usage during the 3-month follow-up period. VAS scores averaged 6.0 before treatment and decreased to 0.5 at 3 months (decrease in pain scores, 92%; P.01). No adverse events were recorded at physical examination or follow-up imaging. The majority of patients with osteolytic metastases had varying degrees of necrosis of the enhancing medullary component of the metastasis at follow-up enhanced MR imaging. Five patients had increased bone density at the site of treated osteolytic metastases at follow-up unenhanced CT at 3 months after MR imaging-guided focused ultrasound.MR imaging-guided focused ultrasound is a noninvasive technique that allows palliative treatment of bone metastases with little or no morbidity.

Noninvasive thermal ablation using magnetic resonance (MR)-guided focused ultrasound (MRgFUS) has been shown to be clinically effective in uterine fibroids, and is being evaluated for ablation of breast, liver, and brain lesions. Recently MRgFUS has been evaluated for palliation of pain caused by bone metastases. We present the clinical results of a multicenter study using MRgFUS for palliation of bone metastases pain. A multicenter study to evaluate the safety and efficacy of MRgFUS palliative treatment of bone metastases was conducted in patients suffering from painful metastatic bone lesions for which other treatments were either ineffective or not feasible. Thirty-one patients with painful bone metastases underwent the MRgFUS procedure in three medical centers. Treatment safety was evaluated by assessing the device-related complications. Effectiveness of pain palliation was evaluated using the visual analog pain score (VAS), and measurable changes in the intake of opioid analgesics. Thirty-six procedures were performed on 31 patients. Mean follow-up time was 4 months. 25 patients underwent the planned treatment and were available for 3 months post-treatment follow-up. 72% of the patients (18/25) reported significant pain improvement. Average VAS score was reduced from 5.9 prior to treatment to 1.8 at 3 months post treatment. 67% of patients with recorded medication data reported a reduction in their opioid usage. No device-related severe adverse events were recorded. The results suggest that MRgFUS has the ability to provide an accurate, effective, and safe noninvasive palliative treatment for patients with bone metastases.

Magnetic Resonance guided Focused Ultrasound (MRgFUS) is a non-invasive, non-ionizing treatment producing thermal ablation using high intensity focused ultrasound and MR thermometry to denervate pain from bone metastases. A recent phase III study comparing MRgFUS to sham treatment for a painful bone metastasis allowed patients to be treated with concurrent chemotherapy as long as the regimen was stable for at least 4 weeks. We performed a retrospective analysis of the safety of combination MRgFUS with active systemic chemotherapy in patients treated on this study.

Purpose. To assess the value of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) parameters to monitor residual tumor following non-invasive MRI-guided focused ultrasound surgery (MRIgFUS) of breast tumors. Methods. DCE-MRI data were acquired before and after the MRIgFUS treatment of small breast tumors (d

PURPOSE To evaluate the feasibility of treating breast neoplasms with use of magnetic resonance (MR) imaging–guided focused ultrasound (US) surgery. MATERIALS AND METHODS Twenty-four female patients, each with a single biopsy-proven breast carcinoma, who were considered to be at increased surgical risk or who had refused surgery underwent MR imaging–guided focused US surgery as an adjunct to their chemotherapeutic regimen of tamoxifen. Follow-up included routine studies to rule out metastatic disease and MR studies with and without contrast material infusion in the treated breast (10 days and 1, 3, and 6 months after the treatment session). Percutaneous biopsy was performed after 6-month follow-up, and if residual tumor was present, a second MR imaging–guided focused US surgery treatment session was performed, followed by repeat biopsy 1 month later. RESULTS Twenty-three of 24 patients completed the protocol, with only one minor complication associated with the treatment sessions (second-degree skin burn resolved with local treatment). Follow-up MR studies demonstrated a varying hypointense treatment margin (range, 1–11 mm), which represents destruction of tissue beyond the visible tumor. Absence of enhancement may be an indicator of tumor destruction (18 of 19 patients with negative biopsy results) whereas persistent enhancement suggested tumor residue (three of five patients with residual tumor). Overall, 19 of 24 patients (79%) had negative biopsy results after one or two treatment sessions. CONCLUSION MR imaging–guided focused US surgery of breast tumors is a safe, repeatable, and promising method of focal tumor destruction.

e15575 Background: About one third of patients with renal cell carcinoma (RCC) present with or develop bone metastases during their disease. Treatment of metastatic RCC has been revolutionized with...

In the present study we evaluated the predictive value of pretransjugular intrahepatic portosystemic shunt (TIPS) portal perfusion as assessed by Doppler ultrasonography for the onset of chronic encephalopathy after TIPS.A total of 231 cirrhotic patients were followed-up prospectively after TIPS placement. The pattern of intrahepatic portal flow was assessed before TIPS. Patients were divided into two groups according to Doppler findings. Group 1 comprised patients with prograde portal flow (n = 200), whereas group 2 comprised those with loss of portal perfusion (hepatofugal or back-and-forth flow or portal vein thrombosis; n = 31). The presence of chronic encephalopathy during a median follow-up of 32 months was prospectively recorded. The prognostic value of the following parameters for the onset of chronic recurrent encephalopathy after TIPS was evaluated: age, presence of encephalopathy before TIPS, alcoholism, Pugh score, and loss of portal perfusion before TIPS. The independent prognostic value of each variable was tested with a multiple logistic regression analysis.The two groups were comparable in terms of age, incidence of prior episodes of hepatic encephalopathy, and portacaval gradient before and after the procedure; however, liver failure was more severe in patients in group 2 (Pugh score: 9.2 +/- 1.9 vs 10.3 +/- 1.7). The 3-yr survival was identical for both groups; 25% of the 200 patients in group 1 developed chronic encephalopathy as compared to 6% of the 31 patients in group 2 (p = 0.03). Multiple logistic regression analysis demonstrated that loss of portal perfusion and age65 yr were the only independent predictors of the onset of post-TIPS chronic encephalopathy (odds ratios 0.24 and 1.98, respectively).Cirrhotic patients with loss of portal perfusion before TIPS were protected against post-TIPS chronic hepatic encephalopathy despite a more severe liver dysfunction at baseline. The only other independent predictive factor for the onset of this complication was age.

PURPOSE To assess the clinical impact of computed tomographic (CT) fluoroscopy (CTF) with regard to procedure time and success rate for CT image-guided biopsy procedures. MATERIALS AND METHODS One hundred ninety consecutive patients referred to the same radiologist underwent biopsy procedures performed with use of a CT scanner equipped with fluoroscopic capabilities during a 15-month period. CTF procedures were performed predominantly by means of a continuous fluoroscopic technique, with typical exposure factors of 50 mA at 120 kV and a slice thickness of 10 mm. The total procedure time, fluoroscopy time, and complication and procedure success rates were documented prospectively in this group. A control group consisted of retrospective analysis of 93 consecutive patients who had undergone a classic CT-guided procedure performed by the same radiologist. RESULTS Procedure success rate was increased in the CTF group (93.7 versus 88.2%), although the difference was not statistically significant ( P >.05: Fisher exact test). A statistically significant difference was noted when comparing mean procedure times (CTF, 27.56 minutes; range, 20–60 minutes versus control, 43.17 minutes; range, 35–80 minutes; P t test). CONCLUSION CT fluoroscopy facilitates CT-guided biopsy procedures by allowing visualization of the needle trajectory from skin entry to the target point, allowing procedures to be performed more rapidly and efficiently.

9500 Background: Pain due to bone metastases is a common cause of cancer-related morbidity. Magnetic resonance guided focused ultrasound surgery (MRgFUS) is a non-invasive approach to thermal tissue ablation. This multi-center phase III trial assessed efficacy of MRgFUS compared with sham treatment to alleviate pain due to bone metastases. Methods: Subjects with a painful bone metastasis amenable to MRgFUS treatment for whom radiation therapy was ineffective or contraindicated were randomized 3:1 to MRgFUS or sham treatment in a single blind design. Un-blinding of sham subjects who did not experience significant pain relief within 2 weeks was permitted with crossover allowed to salvage MRgFUS treatment. Pain response and impact on quality of life (QOL) were assessed using the numerical rating scale (NRS) and Brief Pain Inventory-Quality of Life (BPI-QOL). Safety was also assessed. Results: 142 randomized subjects were included in an intent-to-treat analysis. 67% (95%CI: 57.5-76.0%) of 107 subjects in the MRgFUS arm experienced clinically significant pain relief, equating with an anchor descriptor of “much improved” or better at 3 months compared to 20% of 35 sham arm subjects (p

Umbilical hemorrhage from a cutaneous varix treated by transjugular intrahepatic portosystemic shunt (TIPS)

Pain due to bone metastases is a common cause of cancer-related morbidity, with few options available for patients refractory to medical therapies and who do not respond to radiation therapy. This study assessed the safety and efficacy of magnetic resonance-guided focused ultrasound surgery (MRgFUS), a noninvasive method of thermal tissue ablation for palliation of pain due to bone metastases.Patients with painful bone metastases were randomly assigned 3:1 to receive MRgFUS sonication or placebo. The primary endpoint was improvement in self-reported pain score without increase of pain medication 3 months after treatment and was analyzed by Fisher's exact test. Components of the response composite, Numerical Rating Scale for pain (NRS) and morphine equivalent daily dose intake, were analyzed by t test and Wilcoxon rank-sum test, respectively. Brief Pain Inventory (BPI-QoL), a measure of functional interference of pain on quality of life, was compared between MRgFUS and placebo by t test. Statistical tests were two-sided.One hundred forty-seven subjects were enrolled, with 112 and 35 randomly assigned to MRgFUS and placebo treatments, respectively. Response rate for the primary endpoint was 64.3% in the MRgFUS arm and 20.0% in the placebo arm (P.001). MRgFUS was also superior to placebo at 3 months on the secondary endpoints assessing worst score NRS (P.001) and the BPI-QoL (P.001). The most common treatment-related adverse event (AE) was sonication pain, which occurred in 32.1% of MRgFUS patients. Two patients had pathological fractures, one patient had third-degree skin burn, and one patient suffered from neuropathy. Overall 60.3% of all AEs resolved on the treatment day.This multicenter phase III trial demonstrated that MRgFUS is a safe and effective, noninvasive treatment for alleviating pain resulting from bone metastases in patients that have failed standard treatments.

BACKGROUND: Chest tube drainage under radiological guidance has been used with increasing frequency as a treatment option for pleural effusions and pneumothoraxes.OBJECTIVE: To evaluate the safety and usefulness of pleural drainage under radiological guidance for pleural effusion and pneumothorax in a tertiary care university teaching hospital.METHODS: A retrospective study of cases of chest tube placement under radiological guidance over a 12-month period in a university hospital.RESULTS: Fifty-one percutaneous pigtail catheter drainage cases were reviewed (30 patients). Forty-six (90%) chest tubes were inserted as a first-line treatment. The overall success rate of radiological drainage was 88%. Specific success rates were 92%, 85% and 91% for loculated pleural effusion, pneumothorax and empyema, respectively. The complications were few and minor.CONCLUSIONS: Pigtail catheter insertion under radiological guidance is a useful procedure for the treatment of sterile pleural effusion, empyema and pneumothorax. This technique can be used as a first-line procedure in the majority of cases.