Precision pain management in interventional radiology

Pain is a common manifestation of several benign and malignant conditions. Inadequate response to conservative therapies is often succeeded by incremental use of analgesics and opioids; however, such an approach is often ineffective, not well tolerated by patients, and carries the risk of addiction leading to the opioid crisis. Implementing minimally invasive percutaneous procedures, performed by interventional radiologists has proven to be successful in providing safe, effective, and patient-specific therapies across a wide range of painful conditions. In the present narrative review, we will review the repertoire of minimally invasive imaging guided interventions, which have been successfully used to treat common painful benign and malignant conditions. We briefly describe each technique, common indications, and expected results.

Artificial intelligence in radiology: trainees want more

AIM

To understand the attitudes of UK radiology trainees towards artificial intelligence (AI) in Radiology, in particular, assessing the demand for AI education.

MATERIALS AND METHODS

A survey, which ran over a period of 2 months, was created using the Google Forms platform and distributed via email to all UK training programmes.

RESULTS

The survey was completed by 149 trainee radiologists with at least one response from all UK training programmes. Of the responses, 83.7% were interested in AI use in radiology but 71.4% had no experience of working with AI and 79.9% would like to be involved in AI-based projects. Almost all (98.7%) felt that AI should be taught during their training, yet only one respondent stated that their training programme had implemented AI teaching. Respondents indicated that basic understanding, implementation, and critical appraisal of AI software should be prioritized in teaching. Of the trainees, 74.2% agreed that AI would enhance the job of diagnostic radiologists over the next 20 years. The main concerns raised were information technology/implementation and ethical/regulatory issues.

CONCLUSION

Despite the current limited availability of AI-based activities and teaching within UK training programmes, UK trainees' attitudes towards AI are mostly positive with many showing interest in being involved with AI-based projects, activities, and teaching.

Interventional magnetic-resonance-guided cryotherapy combined with microsurgery for recurrent glioblastoma: An innovative treatment?

BACKGROUND

Glioblastoma invariably recurs after primary Stupp tumor therapy and portends a poor prognosis. Cryoablation is a well-established treatment strategy for extra-cranial tumors. The safety and efficacy of interventional MR-guided cryoablation (iMRgC) has not been explored in recurrent glioblastoma.

METHODS

A retrospective analysis of data collected over a period of 24 months was performed. The inclusion criteria were: (I) recurrent glioblastoma despite Stupp protocol; (II) MRI followed by histological confirmation of recurrent glioblastoma; (III) location allowing iMRgC followed by microsurgical resection; and (IV) patient's consent. The primary objective was to assess feasibility in terms of complications. The secondary objective was to analyze progression-free survival (PFS), post-iMRgC survival and overall survival (OS).

RESULTS

The study included 6 patients, with a mean age of 67±7.6 years [range, 54-70 years]. No major complications were observed. Median PFS was 7.5 months [IQR 3.75-9.75] and 6-month PFS was 50%. Median post-iMRgC survival was 9 months [IQR 7.5-15.25] and 6-month post-iMRgC survival was 80%. Median OS was 22.5 months [IQR 21.75-30].

CONCLUSION

iMRgC for recurrent glioblastoma demonstrated a good safety profile, with no major complications. Our data suggest improved PFS and OS.

TRIAL REGISTRATION NUMBER

No. IRB00011687 retrospectively registred on July 7th 2021.

Robotic total pelvic exenteration for rectal cancer: case report and review of literature

We describe a case report of a robotic total pelvic exenteration (TPE) performed for a locally advanced rectal cancer at our institution in August 2018. Technical details and comparison with published literature are discussed. A 62-year-old patient with a locally advanced low rectal cancer T4N1cM0 with extramural vascular invasion (EMVI) underwent an elective robotic pelvic clearance performed by the urology and colorectal teams. He received neoadjuvant long-course chemo-radiotherapy to downstage the rectal cancer. The primary tumour was T4N1c with involvement of the bladder (trigone area) and prostate. After neoadjuvant therapy, MRI scan showed tumour regression grade 4 (TRG4). The patient underwent single docking totally robotic pelvic clearance. Patient's body mass index (BMI) was 32. The operative time was 400 minutes with the docking time of 15 minutes. There were no intraoperative complications, and the blood loss was 100ml. Histology was ypT4b, ypN1b, ypMx with 2/9 positive lymph nodes, and there was a complete resection by >1mm at all margins. The postoperative complications were ileus and urinary tract infection. Length of stay was 11 days complicated by prolonged ileus requiring total parenteral nutrition (TPN). The 30-day follow-up had no postoperative complications or readmission. The robotic approach is safe and feasible for multiorgan resections for locally advanced pelvic cancers, with curative intent. The literature supports it by highlighting the advantages of robotic pelvic surgery: better access, stable platform, quick inter-specialty change of operator by use of dual console and superior visualisation.

PMMA Bone Cement in Interventional Oncology

Polymethylmethacrylate (PMMA) bone cement is increasingly being used for percutaneous minimally invasive treatments of patients suffering from bone malignancies. PMMA is composed of a polymeric powder and a monomeric liquid. Once mixed, the polymerization process begins and leads to a viscous fluid that can be injected through a bone trocar. Cement progressively hardens within the bone, leading to a viscoelastic solid material. PMMA interacts with the surrounding cancellous bone through mechanical interlocking via interdigitations in trabecular bone. It can also bond with hardware, such as titanium screws, as it penetrates the macro- and micro-irregularities of the hardware. PMMA itself has no antineoplastic effects but may be used as a stand-alone treatment to provide pain palliation and bone consolidation through mechanical reinforcement, notably in areas with high compression load. It can also be used to reinforce the anchorage of screws in case of a landing zone with poor bone quality due to underlying malignant osteolysis.

Pain relief and local tumour control following percutaneous image-guided cryoablation for spine metastasis: a 12-year single-centre experience

AIM

To assess pain relief and local tumour control retrospectively in spinal metastases undergoing cryoablation.

MATERIALS AND METHODS

Between May 2008 and September 2020, 46 metastases in 41 consecutive patients (mean age 59.7±4.4 [SD] years; range 27-84) were treated with cryoablation in 42 interventional sessions. Patient demographics, procedural data, complications, pain, and local tumour control were analysed retrospectively.

RESULTS

Thirty-one patients (36 spine metastases; 32 sessions) were treated for pain relief and 10 (10 metastases; 10 sessions) for local tumour control. Clinical success was reached in 30/32 (93.8%) interventional palliative sessions. Mean pre-procedural numerical pain rate scale was 6.2±1.7 (SD), and dropped significantly to 3.5±1.8 (SD), 1.9±1.7 (SD), and 1.9±1.8 (SD) at 24-h, 1-month and at the last available follow-up (median 16.5±23.2 [SD] months), respectively. For patients requiring local tumour control, primary clinical success was reached in 6/10 (60%) spinal metastases at median 25-months follow-up. The overall complication rate was 8%, with no secondary fractures or iatrogenic thermal-mediated nerve injuries reported.

CONCLUSION

Percutaneous image-guided cryoablation of spinal metastases is safe and effective in achieving pain relief and local tumour control.

Robot-Assisted Bone Cement Injection

In this article, assistance to bone cement injection is studied, with a focus on vertebroplasty, a procedure dedicated to the treatment of vertebral compression fractures. A robotic system that can remotely be operated at pressures up to 140 bar is presented. It improves cement polymerization control, combining a cold passive exchanger that slows down the cement curing in the syringe and an active exchanger that controls the injected cement temperature. The cement remote injection uses a rate control teleoperation strategy with force feedback to help monitoring the cement state. In addition to laboratory assessments, cadaver experiments were performed to illustrate the satisfactory operation of the whole system.

Survey of research participation amongst UK radiology trainees: aspirations, barriers, solutions and the Radiology Academic Network for Trainees (RADIANT)

AIM

To inform the activity of the newly formed Radiology Academic Network for Trainees (RADIANT) regarding the current level of interest, engagement, and barriers experienced by UK radiology trainees to undertake research.

MATERIALS AND METHODS

A web-based survey containing nine questions was sent to the UK radiology training programme directors for distribution to trainees. The survey was also distributed to all trainee members of the RADIANT network. This led to 224 responses over a period of 2 months.

RESULTS

A large proportion of respondents indicated a desire to participate in research in the next 12 months 72.3% (n=162). The most frequently reported barriers to research were lack of time (60.7%, n=136), lack of awareness of local/departmental opportunities (53.6%, n=120), and limited experience in research statistics (46%, n=103). The most favoured factor that would improve access to research was structured research training opportunities, qualified as a project with clear goals and timeline (71%, n=159), protected time for research (68.8%, n=154), and local or national trainee research networks (40.2%, n=90 and 37.1%, n=83, respectively).

CONCLUSION

Many radiology trainees would like to participate in research, but multiple barriers exist. The formation of RADIANT is seen as a key part of a multifaceted approach to improving access to quality research activity alongside support from local and regional training bodies.

The Cryo-immunologic effect: A therapeutic advance in the treatment of glioblastomas?

The immunotherapy of cerebral glioblastoma has become a hot topic. Immune checkpoint blockade antibodies have progressively acquired a role in the management of malignant tumors. A multimodal approach using surgery, radiotherapy, chemotherapy in combination with immunotherapy represent a potent weapon against glioblastomas. In parallel, clinical applications of cryotherapy-freezing tumors based on repetition of rapid freeze-slow thaw cycle-for various cancers such as skin, lung, breast, esophagus, hepatic, kidney, prostate and bone tumors were developed. The future immunomodulatory approaches might be combined with brain tumors cryoablation to increase the cryoimmune response. The objective of this study was to analyze from the literature the relationship between cerebral cryosurgery and immunomodulation using PRISMA method. The animals' studies demonstrate the dendritic cells maturation and activation with the enhancement of antigen-presenting function after cryotherapy suggesting the potential usefulness of the association of cryotherapy and immunomodulator in the management of gliomas.

Percutaneous image-guided double oblique anterior approach to the acetabulum for cementoplasty

AIM

To report the technique of percutaneous double oblique anterior access to the acetabulum and evaluate its feasibility and safety.

MATERIALS AND METHODS

Pelvic computed tomography (CT) examinations of 60 patients (30 men and 30 women; mean age 62.6±13.2 years) were retrieved randomly from the picture archiving and communication system (PACS). A virtual intraosseous trajectory was defined on both sides on the axial CT images with the entry point marked 1 cm above the anterosuperior iliac spine and the endpoint defined just above the level of the ischial spine at the midpoint of the posterior acetabulum. Patient age, sagittal oblique angulation, axial oblique angulation, length of intraosseous trajectory, distance from the hip joint, thickness of the iliac bone cortex, and intervening structure(s) between the skin and the bone entry points were recorded.

RESULTS

The mean sagittal and axial oblique angulations were 34.2±4.5° and 31.5±6.7°, respectively, and mean length of the intraosseous trajectory was 11.8±0.9 cm. The axial oblique angle and length of the intraosseous trajectory were significantly lower in the female than the male population (p<0.05). None of the virtual trajectories traversed the hip joint. In 112/120 trajectories (93.3%), there were no cortical breaches in the iliac bones. In eight trajectories in four patients, the virtual trajectory crossed either the medial iliac cortex (4/120; 3.3%) or the medial iliac cortex and the iliacus muscle (4/120; 3.3%).

CONCLUSION

The anterosuperior iliac and ischial spines can be used safely and reliably as landmarks to perform the double oblique anterior approach.

[Percutaneous MR-guided prostate cancer cryoablation: Predictive factors and oncologic outcomes]

OBJECTIVE

To determine the pejorative predictive factors on oncologic outcomes of percutaneous MR-guided whole gland prostate cancer cryoablation (CA).

METHODS

Medical records of patients treated from 2009 to 2012, to assess medium-term oncologic outcomes, were reviewed. Prostate biopsies were performed in local recurrence suspicion (biochemical failure, MR follow-up failure).

RESULTS

Among 18 patients, mean age of 72.6 (61-78), 2 (11 %) and 7 (38.9 %) biological and reported biopsy-proven local recurrence respectively with our initial technic of CA. Mean follow-up and recurrence were 56.3 (±21.7) and 20.7 (±13.9) months respectively. A previous treatment of prostate cancer (P=0.5), pre-treatment PSA (P=0.2), pre-treatment Gleason/ISUP score (P=0.4), nadir PSA post-CA (P=0.22) were not associated with recurrence. Bilateral positive cores appears as a pejorative predictive factor (P=0.04). However mean pre-treatment positive cores percentage, 25 (±16.5) in responding patients versus 40.7 (±25.2) in case of recurrence, and maximum percentage of cancer extent in each positive core, 10.6 (±9.3) in responding patients versus 18.7 (±16.5) in case of recurrence, seemed associated with local recurrence after prostate CA but our analysis wasn't able to find a difference (P=0.09 and P=0.3 respectively) due to a lack of power.

CONCLUSION

Bilateral positive cores appears as a pejorative predictive factor. In our experience, important tumor volume seem to be a pejorative predictive factor for oncologic outcomes after PCA whereas treatment, PSA, Gleason/ISUP score, nadir PSA are not.

LEVEL OF EVIDENCE

4.

Transforaminal Insertion of a Thermocouple on the Posterior Vertebral Wall Combined with Hydrodissection during Lumbar Spinal Radiofrequency Ablation

The purpose of the present article is to describe the technique of transforaminal insertion of an ultrathin thermosensor in the anterior epidural space in 13 patients treated by radiofrequency ablation. The mean time taken to position the thermosensor was 10.6 minutes (range, 5-38 minutes). Technical success was 93% (correct positioning in 13/14 levels). Additional hydrodissection was performed through the same access in 11 cases. No postoperative neural deficit was elicited in any of the cases.

Percutaneous extra-spinal cementoplasty in patients with cancer: A systematic review of procedural details and clinical outcomes

PURPOSE

To perform a systematic review of technical details and clinical outcomes of percutaneous extra-spinal cementoplasty in patients with malignant lesions.

MATERIALS AND METHODS

PUBMED, MEDLINE, MEDLINE in-process, EMBASE and the Cochrane databases were searched between January 1990 and February 2019 using the keywords «percutaneous cementoplasty», «percutaneous osteoplasty» and «extra-spinal cementoplasty». Inclusion criteria were: retrospective/prospective cohort with more than 4 patients, published in English language, reporting the use of percutaneous injection of cement inside an extra-spinal bone malignant tumour using a dedicated bone trocar, as a stand-alone procedure or in combination with another percutaneous intervention, in order to provide pain palliation and/or bone consolidation.

RESULTS

Thirty articles involving 652 patients with a total of 761 lesions were reviewed. Mean size of lesion was 45mm (range of mean size among publications: 29-73mm); 489 lesions were located in the pelvis, 262 in the long bones of the limbs and 10 in other locations. Cementoplasty was reported as a stand-alone procedure for 60.1% of lesions, and combined with thermal ablation for 26.2% of lesions, implant devices for 12.3% of lesions, and balloon kyphoplasty for 1.4% of lesions. The mean volume of injected cement was 8.8mL (range of mean volume among publications: 2.7-32.2mL). The preoperative visual analogic scores ranged between 3.2 and 9.5. Postoperative scores at last available follow-up ranged from 0.4 to 5.6. Thirteen papers reported a reduction of the visual analogic scores of 5 points or more. Nerve injury was the most frequent symptomatic leakage (0.6%).

CONCLUSION

Percutaneous extra-spinal cementopasty is predominantly performed as a stand-alone procedure and for lesions in the bony pelvis. It appears to be an effective tool to manage pain associated with malignant bone tumours. There is however a lack of standardization of the technique among the different publications.

Preclinical evaluation of the atraumatic nature of a spring loaded blunt tip coaxial needle in a swine model

PURPOSE

To test in vivo in an animal model the inherent atraumatic characteristics of the spring loaded blunt tip of a coaxial needle (Gangi-SoftGuard®, Apriomed, Sweden) against a conventional sharp stylet coaxial needle.

MATERIAL AND METHODS

The study was conducted on a 40kg male swine that was its own control for a vascular trauma model. The procedure consisted of voluntary attempts to transfix and traverse the artery/aorta under continuous real-time angiogram. Test and control needles were positioned in the region of the intercostal, superior mesenteric and femoral/deep femoral arteries, and in the aorta. Computed tomography (CT) angiogram was performed post trauma to check for bleeding in the form of extravasation of contrast material. One attempt was performed per site and needle, except for the intercostal artery where a second attempt was done with the test needle, resulting in a total of 4 and 5 tests for the control and test needles, respectively.

RESULTS

With the spring loaded blunt tip, no vascular trauma or bleeding was noted in the intercostal, superior mesenteric and femoral arteries, nor in the aorta. Vascular spasm that recovered with time was noted during the second attempt to transfix the same intercostal artery. There were consistent vascular traumas and bleedings with the control needle in all three tested arteries and the aorta, confirmed on angiogram as well as CT angiogram.

CONCLUSION

The atraumatic feature offered by the spring loaded blunt tip prevented vascular trauma during the 5 attempts made to transfix the artery/aorta in a swine.