Emerging Potential of Microwave Ablation for Primary Aldosteronism Resulting From Unilateral Aldosterone-producing Adenoma

Primary aldosteronism (PA) is the most prevalent form of secondary hypertension and is most commonly caused by an adrenal adenoma or bilateral adrenal hyperplasia. Minimally invasive adrenalectomy is the treatment of choice for unilateral disease. Here, we report the case of a 57-year-old man with previous bladder cancer who was referred for evaluation of resistant hypertension and hypokalemia. Diagnostic workup indicated PA with computed tomography imaging revealing a left adrenal adenoma and adrenal venous sampling lateralizing to the left adrenal. He was therefore referred for a left adrenalectomy using a retroperitoneoscopic approach. However, surgery was complicated by significant perinephritis related to previous bladder cancer immunotherapy and, in view of an identifiable adrenal adenoma, a partial adrenalectomy was performed. Despite histology confirming removal of an adrenal adenoma, he remained hypertensive and hypokalemic with persistent PA. He underwent a computed tomography-guided percutaneous thermal (microwave) ablation of the residual adrenal nodule with immediate biochemical reversal of PA. Six years postprocedure, he remains biochemically and clinically cured from PA. This article presents the details of the case and reviews the literature on long-term outcomes for patients undergoing thermal ablation and adrenalectomy, suggesting that thermal ablation may be a viable alternative for selected patients.

Irreversible Electroporation for Hepatic Tumors: Protocol Standardization Using the Modified Delphi Technique

PURPOSE

A consensus study of panelists was performed to provide a uniform protocol regarding (contra) indications, procedural parameters, perioperative care, and follow-up of irreversible electroporation (IRE) for the treatment of hepatic malignancies.

MATERIALS AND METHODS

Interventional radiologists who had 2 or more publications on IRE, reporting at least 1 patient cohort in the field of hepatobiliary IRE, were recruited. The 8 panelists were asked to anonymously complete 3 iterative rounds of IRE-focused questionnaires to collect data according to a modified Delphi technique. Consensus was defined as having reached 80% or greater agreement.

RESULTS

Panel members' response rates were 88%, 75%, and 88% in rounds 1, 2, and 3, respectively; consensus was reached on 124 of 136 items (91%). Percutaneous or intraoperative hepatic IRE should be considered for unresectable primary and secondary malignancies that are truly unsuitable for thermal ablation because of proximity to critical structures. Absolute contraindications are ventricular arrhythmias, cardiac stimulation devices, and congestive heart failure of New York Heart Association class 3 or higher. A metal stent outside the ablation zone should not be considered a contraindication. For the only commercially available IRE device, the recommended settings are an inter-electrode distance of 10-20 mm and an exposure length of 20 mm. After 10 test pulses, 90 treatment pulses of 1500 V/cm should be delivered continuously, with a pulse length of 70-90 μs. The first post-procedural follow-up should take place 1 month after IRE and thereafter every 3 months, using cross-sectional imaging plus tumor marker assessment.

CONCLUSIONS

This article provides recommendations, created by a modified Delphi consensus study, regarding patient selection, workup, procedure, and follow-up of IRE treatment for hepatic malignancies.

Percutaneous irreversible electroporation with systemic treatment for locally advanced pancreatic adenocarcinoma

Background

The prognosis for unresectable locally advanced pancreatic adenocarcinoma (LAPC) remains poor. There is increasing interest in modern ablative techniques to improve outcomes. We report on the potential value of integrating percutaneous irreversible electroporation (IRE) in patients undergoing systemic chemotherapy.

Methods

Seventy-five patients with unresectable pancreatic carcinoma underwent percutaneous IRE after chemotherapy using computerised tomography guidance under general anaesthesia. Postoperative immediate and 30-day morbidity and mortality, progression-free (PFS) and overall survival (OS) were evaluated.

Results

Post-procedural immediate and 30-day mortality rates were both zero. All-grade adverse events were 25%. Median in-patient stay was 1 day (range, 1-5 days). Median OS and PFS post-IRE for LAPC were 27 and 15 months respectively. Four patients with LAPC down-staged post-IRE ablation to be surgically resectable, with R0 resections in 3 cases.

Conclusions

These results suggest that percutaneous IRE ablation of unresectable LAPC is safe to integrate with standard-of-care chemotherapy and may improve survival, which provides a template for further evaluation in prospective randomized clinical trials.

The EFSUMB Guidelines and Recommendations for the Clinical Practice of Contrast-Enhanced Ultrasound (CEUS) in Non-Hepatic Applications: Update 2017 (Short Version)

The updated version of the EFSUMB guidelines on the application of non-hepatic contrast-enhanced ultrasound (CEUS) deals with the use of microbubble ultrasound contrast outside the liver in the many established and emerging applications.

The EFSUMB Guidelines and Recommendations for the Clinical Practice of Contrast-Enhanced Ultrasound (CEUS) in Non-Hepatic Applications: Update 2017 (Long Version)

The updated version of the EFSUMB guidelines on the application of non-hepatic contrast-enhanced ultrasound (CEUS) deals with the use of microbubble ultrasound contrast outside the liver in the many established and emerging applications.

Evaluation of Perfusion Quantification Methods with Ultrasound Contrast Agents in a Machine-Perfused Pig Liver

PURPOSE

To evaluate dynamic contrast-enhanced ultrasound (DCEUS) as a tool for measuring blood flow in the macro- and microcirculation of an ex-vivo machine-perfused pig liver and to confirm the ability of DCEUS to accurately detect induced flow rate changes so that it could then be used clinically for monitoring flow changes in liver tumors.

MATERIALS AND METHODS

Bolus injections of contrast agents in the hepatic artery (HA) and portal vein (PV) were administered to 3 machine-perfused pig livers. Flow changes were induced by the pump of the machine perfusion system. The induced flow rates were of clinical relevance (150 - 400 ml/min for HA and 400 - 1400 ml/min for PV). Quantification parameters from time-intensity curves [rise time (RT), mean transit time (MTT), area under the curve (AUC) and peak intensity (PI)] were extracted in order to evaluate whether the induced flow changes were reflected in these parameters.

RESULTS

A linear relationship between the image intensity and the microbubble concentration was confirmed first, while time parameters (RT and MMT) were found to be independent of concentration. The induced flow changes which propagated from the larger vessels to the parenchyma were reflected in the quantification parameters. Specifically, RT, MTT and AUC correlated with flow rate changes.

CONCLUSION

Machine-perfused pig liver is an excellent test bed for DCEUS quantification approaches for the study of the hepatic vascular networks. DCEUS quantification parameters (RT, MTT, and AUC) can measure relative flow changes of about 20 % and above in the liver vasculature. DCEUS quantification is a promising tool for real-time monitoring of the vascular network of tumors.

Evaluation of the Accuracy of Liver Lesion DCEUS Quantification With Respiratory Gating

Confidence in the accuracy of dynamic contrast enhanced ultrasound (DCEUS) quantification parameters is imperative for the correct diagnosis of liver lesion perfusion characteristics. An important source of uncertainty in liver DCEUS acquisitions is artifacts introduced by respiratory motion. The objective of this study is to construct a respiratory motion simulation model (RMSM) of dual contrast imaging mode acquisitions of liver lesions in order to evaluate an algorithm for automatic respiratory gating (ARG). The respiratory kinetics as well as the perfusion models of the liver lesion and parenchyma used by the RMSM were solely derived from clinical data. The quality of fit (of the DCEUS data onto the bolus kinetics model) depends on the respiration amplitude. Similar trends in terms of quality of fit as a function of respiration amplitude were observed from RMSM and clinical data. The errors introduced on the DCEUS quantification under the influence of respiration were evaluated. The RMSM revealed that the error in the liver lesion DCEUS quantification parameters significantly decreased (p < 0.001) from a maximum of 32.3% to 6.2% when ARG was used. The use of RMSM clearly demonstrates the capability of the ARG algorithm in significantly reducing errors introduced from both in-plane and out-of-plane respiratory motion.

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part III - Abdominal Treatment Procedures (Long Version)

The third part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound (INVUS) assesses the evidence for ultrasound-guided and assisted interventions in abdominal treatment procedures. Recommendations for clinical practice are presented covering indications, contraindications, and safe and effective performance of the broad variety of these techniques. In particular, drainage of abscesses and fluid collections, interventional tumor ablation techniques, interventional treatment of symptomatic cysts and echinococcosis, percutaneous transhepatic cholangiography and drainage, percutaneous gastrostomy, urinary bladder drainage, and nephrostomy are addressed (long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part III - Abdominal Treatment Procedures (Short Version)

The third part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound assesses the evidence for ultrasound-guided and assisted interventions in abdominal treatment procedures. Recommendations for clinical practice are presented covering indications, contraindications, safety and efficacy of the broad variety of these techniques. In particular, drainage of abscesses and fluid collections, interventional tumor ablation techniques, interventional treatment of symptomatic cysts and echinococcosis, percutaneous transhepatic cholangiography and drainage, percutaneous gastrostomy, urinary bladder drainage, and nephrostomy are addressed (short version; a long version is published online).

Ultrasound-guided trans-rectal high-intensity focused ultrasound (HIFU) for advanced cervical cancer ablation is feasible: a case report

INTRODUCTION

High-intensity focused ultrasound (HIFU) is an ablative treatment undergoing assessment for the treatment of benign and malignant disease. We describe the first reported intracavitary HIFU ablation for recurrent, unresectable and symptomatic cervical cancer.

CASE DESCRIPTION

A 38 year old woman receiving palliative chemotherapy for metastatic cervical adenocarcinoma was offered ablative treatment from an intracavitary trans-rectal HIFU device (Sonablate® 500). Pre-treatment symptoms included vaginal bleeding and discharge that were sufficient to impede her quality of life. No peri-procedural adverse events occurred. Symptoms resolved completely immediately post-procedure, reappeared at 7 days, increasing to pre-procedural levels by day 30.

DISCUSSION AND EVALUATION

This first time experience of intracavitary cervical HIFU suggests that it is feasible for palliation of advanced cervical cancer, with no early evidence of unexpected toxicity. Ethical approval had also been granted for the use of per-vaginal access if appropriate. This route, alone or in combination with the rectal route, may provide increased accessibility in future patients with a redesigned device more suited to trans-vaginal ablations.

CONCLUSION

Intracavitary HIFU is a potentially safe procedure for the treatment of cervical cancer and able to provide symptomatic improvement in the palliative setting.

Early Diagnosis of Intrahepatic Pseudoaneurysm during Radiofrequency Ablation using Contrast-Enhanced Ultrasound

Radiofrequency ablation is one of the more established forms of local treatment in patients with unresectable tumours, including colorectal hepatic metastases. Complications associated with this method of intervention include thermal and mechanical injuries, including vascular insults resulting in haemorrhage or pseudoaneurysm formation. This is the first case demonstrating the detection of post-ablation acute pseudoaneurysm formation identified on the table using contrast-enhanced ultrasound (CEUS) and the subsequent successful management.

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part I. General Aspects (long Version)

This is the first part of the Guidelines on Interventional Ultrasound of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and covers all general aspects of ultrasound-guided procedures (long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part I. General Aspects (Short Version)

This is the first part of the Guidelines on Interventional Ultrasound of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and covers all general aspects of ultrasound-guided procedures (short version; the long version is published online).

Local ablative procedures of the liver

Local ablative therapies have become an important part in the portfolio of treatment for patients with malignant tumors especially in the liver. Although percutaneous ethanol injection still plays a role, current guidelines favor radiofrequency ablation with a higher efficacy for complete tumor destruction. Nevertheless transplantation and surgical resection remain the gold standard due to their superiority in local control and improved survival. In this manuscript we discuss the technique in detail.

Image-guided tumor ablation: standardization of terminology and reporting criteria--a 10-year update

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.

Image-guided tumor ablation: standardization of terminology and reporting criteria--a 10-year update

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 .

Automatic respiratory gating for contrast ultrasound evaluation of liver lesions

Dynamic contrast-enhanced ultrasound (DCEUS) has been used in radiology for many years for lesion detection and characterization. In recent years, more emphasis has been placed on tumor perfusion quantification with DCEUS. To ensure accuracy in both quantitative and qualitative evaluation of liver tumors with DCEUS, sources of noise in clinical data must be identified and, if possible, removed. One of the major sources of such noise is respiratory motion. A new automatic respiratory gating (ARG) algorithm is presented and evaluated with clinical data. The results of the evaluation demonstrate the potential of the ARG algorithm for clinical use as a fast and easy-to-implement method for removing respiratory motion from DCEUS loops.

High-intensity focused ultrasound: advances in technology and experimental trials support enhanced utility of focused ultrasound surgery in oncology

High-intensity focused ultrasound (HIFU) is a rapidly maturing technology with diverse clinical applications. In the field of oncology, the use of HIFU to non-invasively cause tissue necrosis in a defined target, a technique known as focused ultrasound surgery (FUS), has considerable potential for tumour ablation. In this article, we outline the development and underlying principles of HIFU, overview the limitations and commercially available equipment for FUS, then summarise some of the recent technological advances and experimental clinical trials that we predict will have a positive impact on extending the role of FUS in cancer therapy.

Dynamic contrast enhanced ultrasound assessment of the vascular effects of novel therapeutics in early stage trials

Imaging is key in the accurate monitoring of response to cancer therapies targeting tumour vascularity to inhibit its growth and dissemination. Dynamic contrast enhanced ultrasound (DCE ultrasound) is a quantitative method with the advantage of being non-invasive, widely available, portable, cost effective, highly sensitive and reproducible using agents that are truly intravascular. Under the auspices of the initiative of the Experimental Cancer Medicine Centre Imaging Network, bringing together experts from the UK, Europe and North America for a 2-day workshop in May 2010, this consensus paper aims to provide guidance on the use of DCE ultrasound in the measurement of tumour vascular support in clinical trials. Key Points • DCE ultrasound can quantify and extract specific blood flow parameters, such as flow velocity, relative vascular volume and relative blood flow rate. • DCE ultrasound can be performed repeatedly and is therefore ideally suited for pharmacokinetic and pharmacodynamic studies evaluating vascular-targeted drugs. • DCE ultrasound provides a reproducible method of assessing the vascular effects of therapy in pre-clinical and early clinical trials, which is easily translatable into routine clinical practice.

An EFSUMB introduction into Dynamic Contrast-Enhanced Ultrasound (DCE-US) for quantification of tumour perfusion

Dynamic Contrast Enhanced Ultrasound (DCE-US) is an imaging technique that utilizes microbubble contrast agents in diagnostic ultrasound. The EFSUMB guidelines published in 2004, updated in 2008 and 2011 focused on the use of DCE-US, including essential technical requirements, training, investigational procedures and steps, guidance on image interpretation, established and recommended clinical indications and safety considerations. However the quantification of images acquired with ultrasound contrast agents (UCAs) is not discussed in the guidelines. The purpose of this EFSUMB document is to provide some recommendations and descriptions of the quantification of ultrasound images, technical requirements for analysis of time-intensity curves (TICs), methodology for data analysis, and interpretation of the results.

An unusual finding in the inguinal canal of a 26-week pregnant patient

Inguinal herniae are a common pathology found in both paediatric and adult populations. The presence of bowel in the hernia sac is anticipated; however, occasionally other structures may be found within the sac. We describe a case of a leiomyoma that had undergone red degeneration in the inguinal canal of a 26-week pregnant female. With this case report, we hope to expand the diagnostic paradigm in the setting of a painful swelling in the inguinal canal of a pregnant female.

Primary retroperitoneal mucinous cystadenoma-A case study and review of the literature

INTRODUCTION

Primary retroperitoneal tumours of mucinous type are extremely rare and can be further sub-divided into benign, borderline or cystadenocarcinoma. Prompt diagnosis of retroperitoneal tumours is important as the majority are malignant.

PRESENTATION OF CASE

Our case describes a 30year old woman, presenting with a 3month history of intermittent right iliac fossa pain. Abdominal examination demonstrated a mass palpable in the right iliac fossa. Ultrasonography of the abdomen demonstrated a cystic mass with a magnetic resonance imaging (MRI) scan of the pelvis further defining the lesion. Laparoscopy was performed to further evaluate and ultimately remove the retroperitoneal mass. Macroscopic and microscopic examination reported mucinous epithelium of endocervical type with no evidence of invasion. Findings were consistent with primary retroperitoneal mucinous cystadenoma.

DISCUSSION

This is the 19th reported case of a benign primary retroperitoneal mucinous cystadenoma in the English literature. The origin of mucinous cystadenomas in the retroperitoneum is widely debated with multiple theories suggested. Diagnosis of retroperitoneal tumours is important but difficult as serological investigations, ultrasonography, computed topography and magnetic resonance imaging, although useful, cannot allow a confident diagnosis.

CONCLUSION

Primary retroperitoneal mucinous cystadenoma is a benign tumour, however because of the malignant nature of the majority of mucinous retroperitoneal tumours they should be considered in the differential of chronic abdominal pain despite their rarity.

Multimodality imaging of neoplastic and nonneoplastic solid lesions of the pancreas

Solid lesions of the pancreas represent a heterogeneous group of entities that can be broadly classified as either neoplastic or nonneoplastic. Neoplastic lesions include pancreatic adenocarcinoma, pancreatic neuroendocrine tumor, solid pseudopapillary tumor, pancreatoblastoma, pancreatic lymphoma, metastases to the pancreas, and rare miscellaneous neoplasms. Nonneoplastic lesions include focal pancreatitis, fatty infiltration-replacement, intrapancreatic accessory spleen, congenital anomalies such as prominent pancreatic lobulation and bifid pancreatic tail (pancreatic bifidum), and rare miscellaneous lesions (eg, pancreatic sarcoidosis, Castleman disease of the pancreas). A variety of imaging modalities are available for assessing these solid lesions, including ultrasonography (US), computed tomography (CT), magnetic resonance imaging, endoscopic US, and hybrid nuclear imaging techniques such as single photon emission computed tomography-CT and positron emission tomography-CT, each of which has its own strengths and limitations. Accurate diagnosis can be challenging, and use of a multimodality imaging approach is often helpful in equivocal or complex cases. Knowledge of relevant clinical information and key radiologic features is essential for confident lesion characterization and differentiation.

Transrectal high-intensity focused ultrasonography is feasible as a new therapeutic option for advanced recurrent rectal cancer: report on the first case worldwide

High-intensity focused ultrasonography is the only completely non-invasive thermal therapy. To date its applications have been limited but clinical indications are expanding with enhanced technological advances that have increased the accuracy of targeting and decreased the duration of treatment times. We report its first use for rectal cancer.

Contrast enhanced ultrasound in the detection of liver metastases: a prospective multi-centre dose testing study using a perfluorobutane microbubble contrast agent (NC100100)

OBJECTIVE

To conduct a dose testing analysis of perfluorobutane microbubble (NC100100) contrast-enhanced ultrasound (CEUS) to determine the optimal dose for detection of liver metastases in patients with extra-hepatic primary malignancy.

METHODS

157 patients were investigated with conventional US and CEUS. CEUS was performed following intravenous administration of perfluorobutane microbubbles (using one dose of either 0.008, 0.08, 0.12 or 0.36 μL/kg body weight). Three blinded off-site readers recorded the number and locations of metastatic lesions detected by US and CEUS. Contrast enhanced CT and MRI were used as the "Standard Of Reference" (SOR). Sensitivity, specificity and accuracy of liver metastasis detection with US versus CEUS, for each dose group were obtained. Dose group analysis was performed using the Chi-square test.

RESULTS

165 metastases were present in 92 patients who each had 1-7 lesions present on the SOR. Sensitivity of US versus CEUS (for all doses combined) was 38% and 67% (p = 0.0001). The 0.12 dose group with CEUS (78%) had significantly higher sensitivity and accuracy (70%) compared to other dose groups (p < 0.05).

CONCLUSION

The diagnostic performance of CEUS is dose dependent with the 0.12 μL/kg NC100100 dose group showing the greatest sensitivity and accuracy in detection of liver metastases.

Enhancement of liver parenchyma after injection of hepatocyte-specific MRI contrast media: a comparison of gadoxetic acid and gadobenate dimeglumine

PURPOSE

To compare enhancement of liver parenchyma in MR imaging after injection of hepatocyte-specific contrast media.

MATERIALS AND METHODS

Patients (n = 295) with known/suspected focal liver lesions randomly received 0.025 mmol gadoxetic acid/kg body weight or 0.05 mmol gadobenate dimeglumine/kg body weight by means of bolus injection. MR imaging was performed before and immediately after injection, and in the delayed phase at approved time points (20 min after injection of gadoxetic acid and 40 min after injection of gadobenate dimeglumine). The relative liver enhancement for the overall population and a cirrhotic subgroup was compared in T1-weighted GRE sequences. An independent radiologist performed signal intensity measurements. Enhancement ratios were compared using confidence intervals (CIs).

RESULTS

The relative liver enhancement in the overall population was superior with gadoxetic acid (57.24%) versus gadobenate dimeglumine (32.77%) in the delayed-imaging phase. The enhancement ratio between the contrast media was statistically significant at 1.75 (95% CI: 1.46-2.13). In the delayed phase, the enhancement of cirrhotic liver with gadoxetic acid (57.00%) was comparable to that in the overall population. Enhancement with gadobenate dimeglumine was inferior in cirrhotic liver parenchyma (26.85%).

CONCLUSION

In the delayed, hepatocyte-specific phase, liver enhancement after injection of gadoxetic acid was superior to that obtained with gadobenate dimeglumine.

Evidence for a synchronous operative approach in the treatment of colorectal cancer with hepatic metastases: a case matched study

BACKGROUND

Traditionally, a staged operative approach has been used for patients with synchronous colorectal cancer and liver metastases in the U.K. With improved outcomes from hepatic resection the role of a synchronous operative approach needs re-evaluated.

METHODS

32 consecutive patients with colorectal cancer and hepatic metastases that underwent a synchronous operative approach were individually case matched (according to: age; sex; ASA grade; type of hepatic and colonic resection) with patients that had undergone a staged approach. The following variables were analysed: operative blood loss; in hospital morbidity and mortality; duration of hospital stay; disease free and overall survival.

RESULTS

Operative blood losses were: synchronous group, median 475mL (range 150-850mL) vs median 425mL (range 50-1700mL), (p>0.050). There were no significant differences in morbidity: (34% synchronous group vs 59%, p=0.690) with no recorded mortality. Synchronous group had a shorter hospital stay (median 12 days [range 8-21] vs 20 [range 7-51], p=0.008). There were no statistical differences between synchronous and staged patients for disease free and overall survival: 10 months (95% CI 5.8-13.7) versus 14 (95% CI 12.2-16.3; p=0.487) and 21% versus 24% at 5 years (p=0.838).

CONCLUSION

This present study provides supporting evidence for synchronous operative procedures in patients with colorectal liver metastases.

Combined resection and radiofrequency ablation for bilobar colorectal cancer liver metastases

BACKGROUND/AIMS

Traditionally multiple bilobar colorectal liver metastases were not considered suitable for surgical resection. The use of novel adjuncts to hepatic resection to aid tumour clearance is increasing. These include radiofrequency ablation (RFA), which destroys tumour tissue with high local temperatures. The present study reports a series of patients who underwent RFA and resection for bilobar colorectal liver metastases. Comparisons are made with patients undergoing hepatic resection alone over the same time period.

METHODOLOGY

100 consecutive patients underwent curative hepatic resections for colorectal liver metastases (84--resection alone; 16--combined RFA and resection). Most were < 75 years (87%), male (57%), had metachronous disease (65%).

RESULTS

Median follow-up was 37 months. 47/84 hepatic resection and 10/16 combined RFA and resection patients died from recurrent cancer. Median hospital stay, morbidity and mortality were similar in both groups. Actuarial 3-year cancer specific survival rates were 54% for resection alone and 38% for RFA plus resection although this difference was not significant.

CONCLUSION

A combined approach with RFA and resection achieves comparable perioperative outcomes in comparison to liver resection alone. With encouraging oncological outcomes, a combined approach is a potentially curative treatment option for patients with multiple bilobar hepatic metastases.

Quantification of tumor microvascularity with respiratory gated contrast enhanced ultrasound for monitoring therapy

The aim of this feasibility study was to evaluate the response to cytotoxic and antiangiogenic treatment of colorectal liver metastasis using respiratory gated contrast enhanced ultrasonography. Seven patients were monitored with contrast enhanced ultrasound. Sulfur hexafluoride filled microbubbles (SonoVue; Bracco S.P.A., Milan, Italy) were used as contrast agent and the scans were performed with a nonlinear imaging technique (power modulation) at low transmit power (MI=0.06). The mean image intensity in the metastatic lesion and in the normal liver parenchyma were measured as a function of time and time-intensity curves from linearized image data were formed. A novel respiratory gating technique was utilized to minimize the effects of respiratory motion on the images. A reference position of the diaphragm (or other echogenic interface) was selected and all frames where the diaphragm deviated from that position were rejected. The wash-in time (start of enhancement to peak) of metastasis and adjacent normal liver parenchyma was measured from time-intensity curves. The ratio of wash-in time of the lesion to that of the normal parenchyma (WITR) was used to compare the perfusion rate. In a reproducibility study (five patients), the average deviation of WITR was found to be 9%. There was an increase in the WITR for patients responding to treatment (mean WITR increase of 17% after first dose of treatment and 75% at the end of the therapy). In four out of five patients (80%) responding to therapy WITR predicted their response from the first treatment. All six patients that responded to therapy by the end of the therapy cycle (6-9 doses) were correctly predicted by using WITR. The WITR may be a new surrogate marker indicative of early tumor response for colorectal cancer patients undergoing cytotoxic and antiangiogenic therapy. (E-mail: maverk@ucy.ac.cy).

Contrast-enhanced 3D ultrasound in the radiofrequency ablation of liver tumors

Liver metastases and hepatocellular carcinomas are two of the most common causes of cancer deaths in the world. Radiofrequency ablation (RFA) is a well recognized, effective and minimally invasive means of treating malignant hepatic tumors. This article describes the use of contrast-enhanced 3D ultrasound (CE-3DUS) in the staging, targeting and follow-up of patients with liver tumors undergoing RFA. In particular, its value in the management of large hepatic lesions will be illustrated. Current limitations of CE-3DUS and future developments in the technique will also be discussed. In summary, CE-3DUS is useful in the RFA of liver tumors with improved detection and display of occult lesions and recurrence, in the assessment of lesional geometry and orientation for a more accurate planning and guidance of multiple RFA needle electrodes in large tumors and in the evaluation of residual or recurrent disease within the immediate and/or subsequent follow-up periods.

A contrast-enhanced ultrasound study of benign and malignant breast tissue

OBJECTIVE

To determine the diagnostic value of haemodynamic contrast-enhanced ultrasound assessment in benign and malignant breast tissue, using histological examination as the reference standard.

METHODS

An HDI 5000 Phillips ultrasound scanner with microvascular imaging software and 2.5 ml SonoVue (Bracco spa, Milan) contrast was used to scan 50 consecutive patients (32 malignant and 18 benign, 49 with histologically confirmed breast lesions). Time-intensity curves of the regions of interest (ROI) placed over the lesional and normal breast tissues were acquired using QLAB software. The area under the curve (AUC), time to peak (TTP), in-flow gradient (IFG) and peak enhancement (PE) were determined in a standardised manner for each focal breast lesion and the control/normal breast. IFG and AUC in the periphery, and PE and AUC in the centre of the lesions, differed significantly between malignant and benign tumours. In a logistical regression model, AUC in the periphery and the ratio of PE at the tumour centre to that of normal breast were independently predictive of malignancy (p < 0.001), achieving a diagnostic sensitivity of 97% and a specificity of 80% in the 41 tumours in which central vessels could be distinguished.

CONCLUSION

Haemodynamic contrast-enhanced ultrasound assessment can be used to distinguish between benign and malignant breast lesions.

Intra-operative examination of the sentinel node in breast cancer

Intra-operative sentinel node analysis allows immediate progression to axillary clearance in patients with node positive breast cancer and reduces the need for re-operation. Despite this, intra-operative sentinel node analysis is infrequently performed in Ireland. We report our experience using this technique. Sentinel node biopsy was performed in 47 consecutive patients with symptomatic T1-T2 clinically node negative breast cancer. Sentinel nodes were examined intra-operatively by frozen section and imprint cytology and definitive histological assessment was performed on paraffin-embedded tissue. The sentinel node was identified in 46 (98%) patients. Twelve patients had axillary metastases. The sensitivity of intra-operative analysis in identifying nodal metastases was 92%. False negative rate was 8%, negative predictive value 97%, and specificity 100%. Intra-operative analysis of the sentinel node allowed re-operation to be avoided in 92% of patients with axillary node metastases. In our experience this technique can be readily introduced with reliable outcomes.

Radiofrequency ablation of colorectal liver metastases

RFA of liver metastases is promising despite variable results. The differences in reported success rates may be explained by the difference in tumour types/vascularity/aggressiveness, patient selection, operator's expertise and the equipment used. Current limits relate to the small volume of consistent ablation that can be achieved with current equipment. Further technical refinements yielding more reliable ablation with larger surgical margin may reduce local recurrence rate. Although numerous studies have shown effective treatment responses after RFA, the precise impact of RFA on survival of colorectal cancer patients with liver metastases remains unclear. Resection remains the gold standard for patients with liver metastases. In patients with limited number of unresectable lesions and in cases, which are unresectable on the basis of lesional number and localization, RFA is an attractive approach to obtain tumour clearance. Randomised control trials evaluating the value of combined adjuvant systemic chemotherapy are still urgently needed.

Radiological staging of colorectal liver metastases

Rapid advances in imaging technology have improved the detection, characterization and staging of colorectal liver metastases. Multi-modality imaging approach is usually the more useful in staging colorectal liver metastases. Multi-detector computed tomography (MDCT) remains the main imaging modality for preoperative planning, lesion detection and tumour surveillance. Magnetic resonance imaging (MRI) and contrast enhanced ultrasonography (US) are invaluable in problem solving for characterization indeterminate lesions, while contrast enhanced intra-operative ultrasound (CE-IOUS) may be the new gold standard staging tool prior to liver resection. Ultimately, the imaging strategy has to be tailored to the clinical situation to obtain the most relevant information for optimal use of available imaging resources.

Selective continuous vascular occlusion and perioperative fluid restriction in partial hepatectomy. Outcomes in 101 consecutive patients

BACKGROUND

This study documents patient outcomes with one department's approach to performing partial hepatectomy.

METHODS

101 consecutive patients underwent: preoperative dehydration; intraoperative CVP <5 cm H(2)O and selective continuous vascular occlusion.

OUTCOME VARIABLES

pathology; type of hepatic resection; intraoperative blood loss and transfusion rate; 30 day morbidity and mortality; disease free and long term survival. Perioperative liver function was assessed by serial blood sampling.

RESULTS

Of 101 resections: 90% malignant disease; 59% major resections and 35% synchronous procedures. Median estimated blood loss was 400 mL (mean 512 mL, range 50-3000 mL) with postoperative transfusions in 4%. Thirty day morbidity was 20% with no deaths. Median time to local recurrence after colorectal liver metastases resection was 17.1 months with 3 year survival of 51%. Distinct perioperative changes in hepatic function were seen.

CONCLUSION

Selective continuous vascular occlusion and perioperative fluid restriction result in minimal blood loss, low morbidity and zero mortality in patients undergoing partial hepatectomy.

Liver tumor characterization: comparison between liver-specific gadoxetic acid disodium-enhanced MRI and biphasic CT--a multicenter trial

OBJECTIVE

In our multi center trial we compared the potentials of biphasic contrast-enhanced computed tomography (CT) and a novel tissue-specific magnetic resonance imaging (MRI) contrast agent gadoxetic acid disodium in liver lesion characterization.

METHODS

A total of 176 patients with 252 liver lesions were analyzed. There were 104 malignant and 148 benign lesions. High-field strength (1.0 T or 1.5 T) MR systems with T1-and T2-weighted sequences were used with and without fat suppression. After gadoxetic acid disodium injection, dynamic imaging and hepatocyte phase MR imaging were performed. Biphasic with 150 mg I/kg of body weight (100-200 mL) spiral CT was also performed. Image reading consisted of on-site (by study investigators) and fully blinded off-site (by E.S.P; C.R; and A.S) evaluations. The classification (benign or malignant) and characterization (lesion type) outcomes of both techniques were assessed. All imaging results were verified against a standard of reference.

RESULTS

Both on-site and off-site evaluations demonstrated increases in the lesion classification accuracy with gadoxetic acid disodium-enhanced MRI when compared with spiral CT. This improvement was also shown for characterization. Gadoxetic acid disodium was well tolerated.

CONCLUSIONS

Gadoxetic acid disodium offers a safe and diagnostically powerful tool for the evaluation of patients with focal liver lesions with a reliable assessment of lesion classification and characterization.

Prospective multicenter trial evaluating a novel method of characterizing focal liver lesions using contrast-enhanced sonography

OBJECTIVE

The purpose of this study was to assess the clinical value and potential impact of SonoVue-enhanced sonography in the characterization of focal liver lesions.

SUBJECTS AND METHODS

This study included 127 patients with 82 malignant and 52 benign lesions in the liver. Contrast-enhanced sonography was performed using nonlinear imaging modes at low mechanical index (0.1-0.3) to enable real-time visualization of arterial, portal, and late-phase enhancement. Digital recordings of unenhanced sonography and contrast-enhanced sonography were reviewed by on-site investigators and two off-site blinded interpreters. The final diagnosis was based on consensus interpreting of all examinations by another two expert observers with access to CT, MRI, and histologic data; the diagnostic accuracy of contrast-enhanced sonography in identifying the lesion as benign, malignant, or indeterminate and as actual tumor type was compared with baseline sonography.

RESULTS

For on-site investigators, contrast-enhanced sonography reduced the number of indeterminate diagnoses by 67% and improved the sensitivity and specificity to 90.2% and 80.8%, respectively (p < 0.001). For off-site interpreters, contrast-enhanced sonography reduced the number of indeterminate diagnoses by 51-56% (p < 0.001); significantly improved sensitivity and specificity to 90.8-95.4% and 83.7-89.8%, respectively (p < 0.001); eliminated observers' variability (kappa coefficient: 0.66-0.77); and showed no significant difference in all comparisons in the analysis of lesions measuring less than 1.5 cm, 1.5-2.5 cm, and all sizes combined. Contrast-enhanced sonography did not rely on availability of clinical history to enable the diagnoses, and it reduced the need for further imaging investigations 23.7% to 90.4%.

CONCLUSION

Contrast-enhanced sonography improves the characterization of focal liver lesions and may limit the need for further investigations.

The renal sequelae of a novel triphasic approach to blood loss reduction during hepatic resection

AIMS

To report our novel triphasic approach to minimising blood loss during hepatic resection and the renal sequelae.

METHODS

Fifty consecutive patients (median age 63.3 years, range 37-86) underwent hepatic resection. Triphasic approach consisted of: pre-operative bowel preparation with no supplementary fluids; intraoperative intravenous fluid restriction with low central venous pressure (<5 cmH2O) and continuous selective occlusion of the left or right portal structures and corresponding hepatic vein/s. The following variables were analysed: blood loss; transfusion requirements; perioperative renal function; perioperative morbidity and mortality.

RESULTS

Median estimated blood loss was 330 mL (range 50-1200). No patient was transfused intraoperatively, with two patients transfused post-operatively. Median intraoperative urine output prior to hepatic re-perfusion was 28.4 mL/h (range 13.3-40.0) with no patient developing renal impairment. Morbidity occurred in 22% of patients with no documented hepatic failure. There was zero 30-day mortality.

CONCLUSIONS

Pre-operative dehydration and intraoperative fluid restriction combined with continuous selective vascular occlusion minimizes blood loss during hepatic resection with no consequent detriment to renal function.