Development and preclinical evaluation of multifunctional hydrogel for precise thermal protection during thermal ablation

Image-guided thermal ablation (TA), which is less invasive, has been widely applied for treating various kinds of tumors. However, TA still poses the potential risk of thermal damage to sensitive tissue nearby. Therefore, an adjunctive thermoprotective hydrodissection technique with constant injection of 5% glucose (5% Glu) has currently been adopted for clinical application, but this may be hazardous to humans. In this study, a multifunctional hyaluronic acid-based hydrogel (HA-Dc) was developed for hydrodissection. Compared with 5% Glu (the most clinically used solution) and the previously reported F127 hydrogel, the HA-Dc hydrogel was studied in vitro in a porcine liver model and in vivo in a rabbit model and showed good injectability and better tissue retention, stability, and thermoprotective properties throughout the TA procedure. Furthermore, in the preclinical evaluation in a Macaca fascicularis (M. fascicularis) model, HA-Dc showed excellent performance in terms of stricter neuroprotection compared with 5% Glu. In addition, the HA-Dc hydrogel with good biocompatibility and controllable degradation behavior in vivo could be a promising platform for thermal protection during clinical TA procedures.

Pregnancy outcomes following ultrasound-guided high-intensity focused ultrasound in submucous leiomyomas: a retrospective study

OBJECTIVE

To investigate the impact of ultrasound-guided high-intensity focused ultrasound (USgHIFU) on pregnancy in submucous leiomyomas.

MATERIALS AND METHODS

Between October 2015 and October 2021, a retrospective observational study was conducted at the Affiliated Hospital of North Sichuan Medical College, China, for 32 women with submucous leiomyomas who became pregnant after USgHIFU. Pregnancy outcomes, submucous leiomyomas characteristics, and USgHIFU parameters were analyzed.

RESULTS

A total of 17 (53.1%) deliveries were successfully achieved, with full-term delivery in 16 (94.1%) patients and preterm delivery in 1 (5.9%). After USgHIFU, the effective volume in the uterus cavity and the volume of submucous leiomyomas shrank in all 32 patients. The median time to achieve pregnancy after USgHIFU was 11.0 months. Before pregnancy, myoma type was downgraded in 13 (40.6%) patients, stable in 10 (31.3%) and upgraded in 9 (28.1%). The vaginal expulsion rate of submucous leiomyomas was 28.1%, with complete expulsion in 3 (9.4%) patients and partial expulsion in 6 (18.8%). After USgHIFU, the size of submucous leiomyomas did not increase in each trimester (all p > 0.05). The high complications rate during pregnancy (7/17, 41.2%) was associated with advanced maternal age, with only one (5.9%) premature rupture of membranes possibly associated with submucous leiomyomas. There were 6 (35.5%) vaginal delivery and 11 (64.7%) cesarean sections. All 17 newborns developed well, with a mean birth weight of 3482 g.

CONCLUSIONS

In patients with submucous leiomyomas, pregnancies and full-term deliveries can be successfully achieved following USgHIFU, with few related complications.

Efficacy and safety of ultrasound-guided radiofrequency, microwave and laser ablation for the treatment of T1N0M0 papillary thyroid carcinoma on a large scale: a systematic review and meta-analysis

BACKGROUND

To analyze the efficacy and safety of radiofrequency ablation (RFA), microwave ablation (MWA) and laser ablation (LA) in T1N0M0 papillary thyroid carcinoma (PTC) patients by evaluating data on several outcomes on a large scale.

MATERIALS AND METHODS

Literature searches were conducted in PUBMED, EMBASE and the Cochrane Library for studies of thermal ablation (TA) for treating T1N0M0 PTC. Data on the volume reduction rate (VRR) at the 12-month follow-up and final follow-up, complete disappearance rate, local recurrence rate, lymph node metastasis rate, and complication rate of RFA, MWA and LA were evaluated separately. RFA effects were compared between T1aN0M0 and T1bN0M0 patients.

RESULTS

A total of 36 eligible studies were included. RFA presented superior efficacy than MWA in 12-month VRR. At the final follow-up, the difference was slight in subgroups, showing a significant reduction. The complete disappearance rate of LA (93.00%) was higher than that of RFA (81.00%) and MWA (71.00%). Additionally, the local recurrence rate pooled proportions of MWA and RFA were both 2.00%, lower than that of the LA group (3.00%). There was no event of distant metastasis. The lymph node metastasis rates were similar, as RFA (1.00%) had the lowest. For minor complication rates, the pooled proportions of RFA (3.00%) were smaller than those of LA (6.00%) and MWA (13.00%). T1aN0M0 lesions presented with better outcomes than T1bN0M0 lesions.

CONCLUSION

RFA, MWA and LA were reliable in curing PTC, and RFA presented advantages in most outcomes. T1aN0M0 patients may experience fewer side effects than T1bN0M0 patients.

Ablation margin quantification after thermal ablation of malignant liver tumors: How to optimize the procedure? A systematic review of the available evidence

Introduction

To minimize the risk of local tumor progression after thermal ablation of liver malignancies, complete tumor ablation with sufficient ablation margins is a prerequisite. This has resulted in ablation margin quantification to become a rapidly evolving field. The aim of this systematic review is to give an overview of the available literature with respect to clinical studies and technical aspects potentially influencing the interpretation and evaluation of ablation margins.

Methods

The Medline database was reviewed for studies on radiofrequency and microwave ablation of liver cancer, ablation margins, image processing and tissue shrinkage. Studies included in this systematic review were analyzed for qualitative and quantitative assessment methods of ablation margins, segmentation and co-registration methods, and the potential influence of tissue shrinkage occurring during thermal ablation.

Results

75 articles were included of which 58 were clinical studies. In most clinical studies the aimed minimal ablation margin (MAM) was ≥ 5 mm. In 10/31 studies, MAM quantification was performed in 3D rather than in three orthogonal image planes. Segmentations were performed either semi-automatically or manually. Rigid and non-rigid co-registration algorithms were used about as often. Tissue shrinkage rates ranged from 7% to 74%.

Conclusions

There is a high variability in ablation margin quantification methods. Prospectively obtained data and a validated robust workflow are needed to better understand the clinical value. Interpretation of quantified ablation margins may be influenced by tissue shrinkage, as this may cause underestimation.

Contrast-Enhanced Ultrasound-Assessed Supraspinatus Muscle Perfusion Indicates Better Tissue Vitality and Outcome After Supraspinatus Tendon Repair and Subacromial Decompression

OBJECTIVE

Supraspinatus tendon (SSP) tears are a frequent indication for shoulder surgery. Therapy options include physiotherapy, tendon repair and less invasive surgical options like subacromial decompression (SAD). The selection of the most appropriate treatment depends on the specific characteristics and needs of each patient subgroup. Typically, physically active patients are candidates for tendon repair, while a conservative approach is preferred for individuals with severe muscle degeneration or low physical demands. The goal of this study was to assess the impact of contrast-enhanced ultrasound (CEUS)-assessed SSP muscle perfusion on post-operative shoulder function and tendon healing in patients undergoing SSP repair or SAD, thereby enhancing personalized therapy for SSP tendon tears.

METHODS

Two cohorts of patients with SSP tendon tears were treated either by SAD or tendon repair. Pre-operative and 6-month post-operative SSP muscle perfusion was quantified using CEUS and investigated as a surrogate for tissue vitality. The magnetic resonance imaging-derived parameters fatty infiltration and tendon retraction and established shoulder function scores were assessed pre- and post-operatively.

RESULTS

Thirty-five SSP repair patients were compared with 20 SAD patients. Pre-operative perfusion was comparable in the SAD and SSP repair cohorts when a re-tear occurred (wash-in perfusion index = 103.8 ± 124.0 vs. 114.6 ± 155.0, p = 0.83), while being significantly higher among patients with an intact repair (103.8 ± 124 vs. 325.4 ± 388.6, p = 0.006). Below-median pre-operative muscle perfusion was associated with lower post-operative shoulder function (Constant score: 59 ± 28 vs. 78 ± 19, p = 0.012).

CONCLUSION

CEUS can visualize SSP muscle perfusion as a surrogate for tissue vitality and tendon healing, which is associated with better post-operative shoulder function.

Comparison of microwave alone and combined with ethanol ablation for different types of benign mixed thyroid nodules

OBJECTIVE

To evaluate the efficacy and safety of microwave ablation (MWA) plus ethanol ablation (EA) for different types of benign mixed thyroid nodules.

METHODS

A total of 81 patients with 81 benign mixed thyroid nodules were enrolled into the study; 39 were divided to the MWA group and 42 to the combined group (MWA combined with EA). Nodule ablation rate, volume reduction rate (VRR) and surgical complications of all patients were analyzed before and after treatment.

RESULTS

The mean ablation rate were 86.49 ± 6.68% and 90.09 ± 5.79% in the microwave and combined groups respectively, and the ablation rate of nodule decreased as the nodule volume increased. For nodules ≥15 ml in volume, the mean ablation rate of the combined group was higher than that of the microwave group (all P < 0.05). The mean VRR at 12 months postoperatively was 89.58 ± 4.32% in the microwave group and 92.92 ± 3.49% in the combined group, showing statistical significantly different between both arms (P = 0.001). The combined group decreased in volume more significantly than the microwave group for nodules with 20-50% or 50-80% cystic proportions or >15 ml in volume (all P < 0.05). The complication rate was 23.08% and 2.38% respectively.

CONCLUSION

MWA combined with EA is more effective than MWA for treating mixed thyroid nodules. MWA combined with EA may be the first approach for nodules with >20% cystic proportions or volume >15 ml.

Predictors of technical success of percutaneous transhepatic common bile duct stone removal: is it only a matter of stone size?

OBJECTIVES

The common practice is to remove symptomatic common bile duct (CBD) stones in patients. This study aimed to investigate the factors affecting the percutaneous transhepatic removal of CBD stones.

METHODS

We retrospectively analyzed the data of 100 patients (66 men and 34 women; age: 25-105 years, mean 79.1 years) with symptomatic CBD stones who underwent percutaneous transhepatic stone removal (PTSR) from January 2010 through October 2019. After balloon dilation of the ampulla of Vater or bilioenteric anastomosis, the stones were pushed out of the CBD into the small bowel with a balloon catheter. If failed, basket lithotripsy was performed. Technical success was defined as complete clearance of the bile ducts on a cholangiogram.

RESULTS

The technical success rate was 83%, and achieved 90.2% in patients with altered gastroduodenal/pancreatobiliary anatomy. Multivariable analysis revealed that CBD diameter (odds ratio [OR]: 506.460, p = 0.015), failed ERCP (OR: 16.509, p = 0.004), Tokyo guidelines TG18/TG13 severity (grade III; OR: 60.467, p = 0.006), and left-sided transhepatic approach (OR: 21.621, p = 0.012) were risk factors for technical failure. The appropriate cutoff CBD size was 15.5 mm (area under the curve: 0.91). CBD stone size, radiopacity of stones, and CBD angle between retroduodenal and pancreatic portion did not influence technical success.

CONCLUSIONS

PTSR is effective for CBD stone removal in older adults and individuals with altered gastrointestinal tract anatomy. The aforementioned risk factors for technical failure should be considered in preoperative evaluation before PTSR to improve the success rate.

KEY POINTS

• PTSR is effective in symptomatic CBD stone management among older adults and individuals with altered anatomy. Investigating clinical /anatomic factors can guide radiologists toward a more comprehensive preoperative evaluation to maximize the success rate. • Our data indicate that dilated CBD (diameter ≥ 15.5 mm) and left-sided PTBDs reduce the technical success rate by 506-fold and 22-fold, respectively. • Clinical factors such as previous failed ERCP for stone removal and higher severity of acute cholangitis lessen the technical success rate.

Pancreatic fatty replacement as risk marker for altered glucose metabolism and cardiac iron and complications in thalassemia major

OBJECTIVES

This multicenter study assessed the extent of pancreatic fatty replacement and its correlation with demographics, iron overload, glucose metabolism, and cardiac complications in a cohort of well-treated patients with thalassemia major (TM).

METHODS

We considered 308 TM patients (median age: 39.79 years; 182 females) consecutively enrolled in the Extension-Myocardial Iron Overload in Thalassemia Network. Magnetic resonance imaging was used to quantify iron overload (IO) and pancreatic fat fraction (FF) by T2* technique, cardiac function by cine images, and to detect replacement myocardial fibrosis by late gadolinium enhancement technique. The glucose metabolism was assessed by the oral glucose tolerance test.

RESULTS

Pancreatic FF was associated with age, body mass index, and history of hepatitis C virus infection. Patients with normal glucose metabolism showed a significantly lower pancreatic FF than patients with impaired fasting glucose (p = 0.030), impaired glucose tolerance (p < 0.0001), and diabetes (p < 0.0001). A normal pancreatic FF (< 6.6%) showed a negative predictive value of 100% for abnormal glucose metabolism. A pancreatic FF > 15.33% predicted the presence of abnormal glucose metabolism. Pancreas FF was inversely correlated with global pancreas and heart T2* values. A normal pancreatic FF showed a negative predictive value of 100% for cardiac iron. Pancreatic FF was significantly higher in patients with myocardial fibrosis (p = 0.002). All patients with cardiac complications had fatty replacement, and they showed a significantly higher pancreatic FF than complications-free patients (p = 0.002).

CONCLUSION

Pancreatic FF is a risk marker not only for alterations of glucose metabolism, but also for cardiac iron and complications, further supporting the close link between pancreatic and cardiac disease.

KEY POINTS

• In thalassemia major, pancreatic fatty replacement by MRI is a frequent clinical entity, predicted by a pancreas T2* < 20.81 ms and associated with a higher risk of alterations in glucose metabolism. • In thalassemia major, pancreatic fatty replacement is a strong risk marker for cardiac iron, replacement fibrosis, and complications, highlighting a deep connection between pancreatic and cardiac impairment.

A review of contrast-enhanced ultrasound using SonoVue® and Sonazoid™ in non-hepatic organs

Contrast-enhanced ultrasound (CEUS) is a dependable modality for the diagnosis of various clinical conditions. A judicious selection of ultrasound contrast agent (UCA) is imperative for optimizing imaging and improving diagnosis. Approved UCAs for imaging the majority of organs include SonoVue, a pure blood agent, and Sonazoid, which exhibits an additional Kupffer phase. Despite the fact that the two UCAs are increasingly being employed, there is a lack of comparative reviews between the two agents in different organs diseases. This review represents the first attempt to compare the two UCAs in non-hepatic organs, primarily including breast, thyroid, pancreas, and spleen diseases. Through comparative analysis, this review provides a comprehensive and objective evaluation of the performance characteristics of SonoVue and Sonazoid, with the aim of offering valuable guidance for the clinical application of CEUS. Overall, further clinical evidences are required to compare and contrast the dissimilarities between the two UCAs in non-hepatic organs, enabling clinicians to make an appropriate selection based on actual clinical applications.

Can the Unipedicular Approach Replace Bipedicular Percutaneous Balloon Kyphoplasty for the Management of Metastatic Vertebral Lesions?

RATIONALE AND OBJECTIVES

To compare the clinical and radiographic results of bipedicular and unipedicular approaches(UPK and BPK) in the management of metastatic vertebral lesions MATERIALS AND METHODS: Eighty-two patients with 159 metastatic vertebral lesions who underwent UPK(25 cases, 69 lesions) or BPK(57 cases, 90 lesions) were retrospectively evaluated. Clinical results were assessed mainly depending on the Visual Analogue Scale(VAS) score, Oswestry Disability Index(ODI) and Quality of Life(QoL). Radiographic outcomes were evaluated primarily on the basis of bone cement distribution and changes in vertebral body height(VBH). Major and minor complications were systematically evaluated and compared to assess the safety of the 2 procedures.

RESULTS

No statistically significant differences were observed in age, sex, types of lesions, location of lesions, posterior vertebral body and/or pedicle involvement, percentage of vertebra invasion between the groups(p=0.17-0.83). The radiographic parameter VBH was similarly improved in both groups(p=0.26-0.93). There was a significant improvement in the clinical parameters VAS score, ODI, and QoL at each follow-up examination compared with the preoperative results(p<0.001). Significant improvement was observed in the VBH at each follow-up point(p<0.05) compared to pre-procedure. UPK was superior to BPK in terms of the operative duration(p<0.001), cement volume(p=0.004), and surgical complications(p=0.04).

CONCLUSION

Both UPK and BPK resulted in similar clinical and radiographic outcomes in patients with metastatic vertebral lesions. The UPK had advantages including a shorter operation and lower cement volume than the BPK, which may have played an important role in reducing the incidence of complications. UPK can replace BPK in the treatment of metastatic vertebral lesions.

Impact of the introduction of minimally invasive treatments of the thyroid (MITT) for benign thyroid nodules in an Italian hospital: a cost-minimization analysis

BACKGROUND

Prevalence of thyroid nodules is high in the adult population, approaching 60% in women and older people. Most thyroid nodules are benign and asymptomatic. However, a not negligible part of them causes compressive symptoms and/or cosmetic concerns and need to be treated. In the last two decades, minimally-invasive treatments of the thyroid (MITT) have been proposed in routine clinical practice as a reliable cost-effective alternative to surgery in patients with symptomatic benign thyroid nodules (SBTNs).

AIM OF THE STUDY

To perform a cost-minimization analysis comparing direct, indirect and intangible costs of radiofrequency (RFA) and laser thermal ablation (LTA) with traditional surgery in patients with SBTNs.

METHODS

Data of patients treated by MITT for SBTNs from October 1st 2019 to September 30th 2022 in a single Italian tertiary Center were analyzed. Costs were compared to those of traditional surgery reported in the 2022 Associazione Medici Endocrinologi Guidelines on the Management of SBTNs.

RESULTS

In the study lapse, 157 MITT of SBTNs were performed in 148 patients, 114 females and 34 males (mean age: 59 yrs; median age: 57 yrs). Before MITT, the mean thyroid nodule volume was 19 ml; 1 year after MITT, volume reduction rate >50% and symptom relief were achieved in 89% and 93% of patients, respectively. No major complications occurred. Adding up pre-operative, operative and post-operative costs, total direct costs per single procedure are the following: 1361.43 € for LTA when using one optic fiber; 1761.43 € for LTA when using two optic fibers; 1968.53 € for RFA; 3338.39 € for hemithyroidectomy plus isthmectomy; 4034.99 € for total thyroidectomy. Surgery was impactful on direct-i.e., preoperative, operative and postoperative-costs, due to longer operating room occupation time and hospital stay. Overall, a total saving for the Italian National Health Service of 285,377.15 € has been obtained treating the 148 patients by MITT instead of surgery. Likewise, MITT was advantageous also for indirect costs-i.e., those related to "loss of productivity" caused by time off work due to hospital stay and recovery time-, for both the self-employed workers and the Government, the latter saving 53,838.50 € overall. Finally, intangible costs, related to patients' quality of life-e.g., residual surgical scar, stress related to general anesthesia, convalescence, and life-long intake of L-Thyroxine replacement therapy-were all in favor of MITT.

CONCLUSIONS

This real-life cost-minimization analysis demonstrates that LTA and RFA are safe and cost-effective procedures for the treatment of SBTNs. In our 3 years experience, adding the savings of 285,377.15 € for direct costs to those of 53.838,50 € for indirect costs, in total 339,215.65 € were saved. The saving concern patients, the National Health System and the Government.

Hepatocellular carcinoma: Preclinical and clinical applications of nanotechnology with the potential role of carbohydrate receptors

Hepatocellular carcinoma (HCC) is one of the most common types of liver cancer; accounts for 75-85% of cases. The treatment and management of HCC involve different sanative options like surgery, chemotherapy, immunotherapy, etc. Recently, various advancements have been introduced for the diagnosis and targeting of hepatic tumor cells. Among these, biomarkers are considered the primary source for the diagnosis and differentiation of tumor cells. With the advancement in the field of nanotechnology, different types of nanocarriers have been witnessed in tumor targeting. Nanocarriers such as nanoparticles, liposomes, polymeric micelles, nanofibers, etc. are readily prepared for effective tumor targeting with minimal side-effects. The emergence of various approaches tends to improve the effectiveness of these nanocarriers as demonstrated in ample clinical trials. This review focuses on the significant role of carbohydrates such as mannose, galactose, fructose, etc. in the development, diagnosis, and therapy of HCC. Hence, the current focus of this review is to acknowledge various perspectives regarding the occurrence, diagnosis, treatment, and management of HCC.

Quantitative analysis using intraoperative contrast-enhanced ultrasound in adult-type diffuse gliomas with isocitrate dehydrogenase mutations: association between hemodynamics and molecular features

PURPOSE

The relationship between contrast-enhanced ultrasound (CEUS) hemodynamics and the molecular biomarkers of adult-type diffuse gliomas, particularly isocitrate dehydrogenase (IDH), remains unclear. This study was conducted to provide a comprehensive description of the vascularization of adult-type diffuse gliomas using quantitative indicators. Additionally, it was designed to identify any variables with the potential to intraoperatively predict IDH mutation status.

METHODS

This prospective study enrolled patients with adult-type diffuse gliomas between November 2021 and September 2022. Intraoperative CEUS was performed, and CEUS videos were recorded for 90-second periods. Hemodynamic parameters, including the peak enhancement (PE) difference, were calculated based on the time-intensity curve of the region of interest. A differential analysis was performed on the CEUS parameters with respect to molecular biomarkers and grades. Receiver operating characteristic curves for various parameters were analyzed to evaluate the ability of those parameters to predict IDH mutation status.

RESULTS

Sixty patients with adult-type diffuse gliomas were evaluated. All hemodynamic parameters, apart from rising time, demonstrated significant differences between IDH-mutant and IDH-wildtype adult-type diffuse gliomas. The PE difference emerged as the optimal indicator for differentiating between IDH-wildtype and IDH-mutant gliomas, with an area under the curve of 0.958 (95% confidence interval, 0.406 to 0.785). Additionally, the hemodynamic parameters revealed significant differences across both grades and types of adult-type diffuse gliomas.

CONCLUSION

Hemodynamic parameters can be used intraoperatively to effectively distinguish between IDHwildtype and IDH-mutant adult-type diffuse gliomas. Additionally, quantitative CEUS equips neurosurgeons with dynamic perfusion information for various types and grades of adult-type diffuse gliomas.