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Laser ablation (LA) provides us with a new effective therapy for the treatment of thyroid carcinomas and cervical lymph node metastases in the neck, thanks to its minimally invasive and high thermal energy precision, particularly for the patients with recurrent metastatic nodal disease in the neck. Although it is unlikely that LA changes the clinical course, it can be performed repeatedly as a local adjuvant therapy for recurrence of the regional disease and can become a palliative treatment in selected patients who are not eligible for surgery and/or prefer not to undergo further surgery. There are many retrospective and case-series studies that show that LA is safe and effective not just to reduce mortality.

The laser technique for its technical characteristics based on the data available appears as an ideal option in all those particular clinical conditions in which it is necessary to act with sufficient security to avoid major complications, hence in all patients with severe comorbidity and/or with lesions at risk sites and difficult to reach. In this book we described all the clinical applications of laser methodology. Even if the technology has been used since the very beginning of the interventional oncology era, technology is continuously improving, and clinical application expanding. So we foresee a scenario where laser ablation can play an increasing important role among various technologies applied in the clinical practice. In this chapter we report and highlight the future perspective and clinical application of laser ablation.

BACKGROUND: Image-guided interventional procedures around the shoulder are commonly performed in clinical practice, although evidence regarding their effectiveness is scarce. We report the results of a Delphi method review of evidence on literature published on image-guided interventional procedures around the shoulder with a list of clinical indications. METHODS: Forty-five experts in image-guided musculoskeletal procedures from the ESSR participated in a consensus study using the Delphic method. Peer-reviewed papers regarding interventional procedures around the shoulder up to September 2018 were scored according to the Oxford Centre for Evidence-based Medicine levels of evidence. Statements on clinical indications were constructed. Consensus was considered as strong if more than 95% of experts agreed and as broad if more than 80% agreed. RESULTS: A total of 20 statements were drafted, and 5 reached the highest level of evidence. There were 10 statements about tendon procedures, 6 about intra-articular procedures, and 4 about intrabursal injections. Strong consensus was obtained in 16 of them (80%), while 4 received broad consensus (20%). CONCLUSIONS: Literature evidence on image-guided interventional procedures around the shoulder is limited. A strong consensus has been reached for 80% of statements. The ESSR recommends further research to potentially influence treatment options, patient outcomes, and social impact. KEY POINTS: Expert consensus produced a list of 20 evidence-based statements on clinical indications of image-guided interventional procedures around the shoulder. The highest level of evidence was reached for five statements. Strong consensus was obtained for 16 statements (80%), while 4 received broad consensus (20%).

Whether thermal ablation is effective to treat toxic thyroid nodules (TTN) is still unknown. Aim of this review was to achieve more robust evidence on the efficacy of radiofrequency ablation (RFA) in treating TTN in terms of TSH normalization, thyroid scintiscan, and volume reduction rate (VRR). A comprehensive literature search of PubMed/Medline and Scopus was performed in November 2018 to retrieve published studies. Original papers reporting TTN treated by RFA and later followed-up were eligible. Excluded were: articles not within this field, articles with unclear data, overlapping series, case/series reports. Discordances were solved in a final collegial meeting. Information was collected concerning population features, treatment procedure, follow-up, cases with TSH normalization, cases with scintiscan normalization, VRR of nodules. Pooled prevalence of patients with TSH or scintiscan normalization, and pooled VRR over time were calculated. For statistical analysis, the random-effects model was used. Eight articles published between 2008 and 2018 were included. The overall number of AFTN treated by RFA was 205. Five studies used a single session of treatment. The time of follow-up ranged from six to 24 months. The pooled rate of patients with TSH normalization was 57%. The pooled rate of patients with scintigraphically proven optimal response was 60%. The pooled VRR at 1 year was 79%. Baseline nodules volume was associated with the rate of TSH normalization. In conclusion, a moderate efficacy of RFA in treating TTN was found, and this can represent a solid starting point in this field.

Renal ablation is a recognized treatment modality for small renal masses. Cone-beam CT (CBCT) has been recently used in interventional oncology as a promising new guidance device, but this technology still needs to be validated for renal ablations. We aimed to assess the technical success of CBCT applications in renal ablative treatments. Between March 2016 and June 2018, 14 patients (mean age 69, range 54–83, 7F, 7M) underwent 21 renal ablations for histologically proven renal cell carcinoma (RCC). All treatments were performed with ultrasound (US) and CBCT guidance under general anesthesia in a dedicated angiography room setting. CBCT was mainly used to assess needle placement and to exclude complications at the end of the procedure. In two small lesions (

We present the case of a 52-year-old male patient with recurrence of a soft-tissue sarcoma of the left leg treated with percutaneous laser ablation. The patient received the diagnosis of sarcoma for the first time in 2011; further local recurrences and a pulmonary metastatic spread occurred during follow-up, so the patient has been treated several times with chemotherapy, limb-sparing surgery and radiotherapy. In September 2017, a new local recurrence of sarcoma occurred, for which limb amputation was proposed but refused by the patient. Laser ablation with ultrasound guidance was performed, with complete ablation at 6 months and limb salvage.

Benign thyroid nodules are a common clinical occurrence and usually do not require treatment unless symptomatic. During the last years, ultrasound-guided minimally invasive treatments (MIT) gained an increasing role in the management of nodules causing local symptoms. In February 2018, the Italian MIT Thyroid Group was founded to create a permanent cooperation between Italian and international physicians dedicated to clinical research and assistance on MIT for thyroid nodules. The group drafted this list of statements based on literature review and consensus opinion of interdisciplinary experts to facilitate the diffusion and the appropriate use of MIT of thyroid nodules in clinical practice. (#1) Predominantly cystic/cystic symptomatic nodules should first undergo US-guided aspiration; ethanol injection should be performed if relapsing (level of evidence [LoE]: ethanol is superior to simple aspiration = 2); (#2) In symptomatic cystic nodules, thermal ablation is an option when symptoms persist after ethanol ablation (LoE = 4); (#3) Double cytological benignity confirmation is needed before thermal ablation (LoE = 2); (#4) Single cytological sample is adequate in ultrasound low risk (EU-TIRADS ≤3) and in autonomously functioning nodules (LoE = 2); (#5) Thermal ablation may be proposed as first-line treatment for solid, symptomatic, nonfunctioning, benign nodules (LoE = 2); (#6) Thermal ablation may be used for dominant lesions in nonfunctioning multinodular goiter in patients refusing/not eligible for surgery (LoE = 5); (#7) Clinical and ultrasound follow-up is appropriate after thermal ablation (LoE = 2); (#8) Nodule re-treatment can be considered when symptoms relapse or partially resolve (LoE = 2); (#9) In case of nodule regrowth, a new cytological assessment is suggested before second ablation (LoE = 5); (#10) Thermal ablation is an option for autonomously functioning nodules in patients refusing/not eligible for radioiodine or surgery (LoE = 2); (#11) Small autonomously functioning nodules can be treated with thermal ablation when thyroid tissue sparing is a priority and ≥80% nodule volume ablation is expected (LoE = 3).

Microwave ablation (MWA) of lung lesions under guidance of computed tomography (CT) and SIRIO system (Sistema robotizzato assistito per il puntamento intraoperatorio) is providing accurate and real time visualization system. We present a case of 65 y male patient with multiple metastatic lung lesions from gluteal mesenchymal tumor confirmed histopathologically, MWA of two lesions under general anesthesia using double lumen endotracheal tube to exclude LT lung. Complete ablation of lesions was achieved, post-procedure pneumothorax was treated by (Heimlich valve) insertion, 24 hours follow up revealed complete resolution of pneumothorax. In this case report we found that the total procedure time and the total effective radiation dose of the whole procedure were reduced in compared with a previous case of MW ablation of similar sizes lesions under CT guidance only.

As medical imaging advancements have improved the detectability of hepatocellular carcinoma (HCC) in early stages, the approach to percutaneous thermal ablation for curative treatment has concomitantly advanced. Although many centers are adopting cross-sectional imaging to guide percutaneous ablation, the majority of procedures are still performed under ultrasound (US) guidance worldwide. Challenges to ultrasound guidance may present due to relatively poor resolution particularly with small or isoechoic lesions, or due to intervening structures such as the bowel or diaphragm that obstruct lesional visualization. Fusion imaging (FI) systems have been employed to address these challenges. By merging or synchronizing the real-time images from US with a previously obtained cross-sectional study, FI mitigates the inherent limitations of each individual imaging modality and expands procedural feasibility and technical outcomes. This manuscript reviews the current literature on the use of FI during percutaneous thermal ablation of HCC.

To assess mid-term outcome of biodegradable biliary stents (BBSs) to treat benign biliary strictures refractory to standard bilioplasty. Institutional review board approval was obtained and patient consent was waived. 107 patients (61 males, 46 females, mean age 59 ± 16 years), were treated. Technical success and complications were recorded. Ninety-seven patients (55 males, 42 females, aged 57 ± 17 years) were considered for follow-up analysis (mean follow-up 23 ± 12 months). Fisher’s exact test and Mann–Whitney U tests were used and a Kaplan–Meier curve was calculated. The procedure was always feasible. In 2/107 cases (2 %), stent migration occurred (technical success 98 %). 4/107 patients (4 %) experienced mild haemobilia. No major complications occurred. In 19/97 patients (18 %), stricture recurrence occurred. In this group, higher rate of subsequent cholangitis (84.2 % vs. 12.8 %, p = 0.001) and biliary stones (26.3 % vs. 2.5 %, p = 0.003) was noted. Estimated mean time to stricture recurrence was 38 months (95 % C.I 34–42 months). Estimated stricture recurrence rate at 1, 2, and 3 years was respectively 7.2 %, 26.4 %, and 29.4 %. Percutaneous placement of a BBS is a feasible and safe strategy to treat benign biliary strictures refractory to standard bilioplasty, with promising results in the mid-term period. • Percutaneous placement of a BBS is 100 % feasible. • The procedure appears free from major complications, with few minor complications. • BBSs offer promising results in the mid-term period. • With a BBS, external catheter/drainage can be removed early. • BBSs represent a new option in treating benign biliary stenosis.

Purpose To appraise the quality of current guidelines on fine needle aspiration biopsy (FNAB) of thyroid nodules for adults using the AGREE II quality assessment tool. Methods We conducted an online search for guidelines on FNAB of thyroid nodules published between 2013 and October 2018. They were evaluated by four independent reviewers previously trained to apply the AGREE II instrument, which is organized into items and domains. A fifth independent reviewer calculated scores for each domain and guideline as well as inter-appraiser agreement. Results Six sets of guidelines were included, respectively, provided by the American Thyroid Association (ATA), the American Association of Clinical Endocrinologists/American College of Endocrinology/Associazione Medici Endocrinologi (AACE/ACE/AME), the Korean Society of Thyroid Radiology (KSThR), the European Thyroid Association (ETA), the American College of Radiology (ACR) and the Korean Society of Radiology and National Evidence-Based Healthcare Collaborating Agency (KSR/NECA). Five out of the six guidelines (ATA, AACE/ACE/AME, ETA, ACR and KSR/NECA) reached a high level of overall quality, having at least five domain scores >60%. An average level of overall quality was achieved in one case (KSThR recommendations). Inter-appraiser agreement ranged from moderate to excellent. Conclusions Overall, the quality of guidelines on FNAB of thyroid nodules is satisfactory when evaluated using the AGREE II instrument.

PURPOSE The purpose of this study was to assess the feasibility and outcome of transvaginal ultrasound (US)-guided radiofrequency ablation of uterine fibroids assisted by a real-time virtual needle tracking (VT) system. METHODS Between January 2017 and February 2018, 19 patients (age 45 ± 8 y, range 36-53 y) with 25 symptomatic uterine fibroids underwent transvaginal radiofrequency ablation (RFA) at a single center. Mean number of fibroids for patient was 1.7 (min, max: 1-3). Patients with more than one fibroid were 10 (52.6%). Uterine fibroids (mean volume: 13.6 mL; range: 5.3-41.9 mL) were treated with a dedicated internally cooled 17 G 35 cm RF needle with 1 cm or variable active tip and the moving shot technique. An electromagnetic system was used for showing a virtual needle during the procedure. Contrast-enhanced ultrasound evaluation was performed before and immediately at the end of procedure. Feasibility of the procedure, technical success rate, volume percentage reduction at 1, 3 and 6 months, clinical outcome (QOL score) and complications were analyzed. RESULTS Procedure was feasible in 19/19 patients (100%). Technical success was achieved in 100% of 25 treated fibroids. Mean fibroids volume decreased from 13.6 ml at baseline to 5.9 ml at 6 month (reduction rate 62.7%, range 48.5-76.9; p

To assess the feasibility of US-Twenty-three patients with 58 liver metastases underwent microwave ablation guided by image fusion system that combines US withRegistration was successfully performed in all cases with a mean time of 7.8 + 1.7 min (mean + standard deviation), (4.6 + 1.5 min for PET/CECT group versus 10.9 + 1.8 min for PET/CT group, P 0.01). In total, 46/58 (79.3%) tumors were correctly targeted, while 3/28 (10.7%) and 9/30 (30%) were incorrectly targeted in PET/CT and PET/CECT group, respectively (P 0.05). Complete ablation was obtained at 24 h in 70.0% of cases (n = 40 tumors), 23/28 (82.1%) in the PET/CECT group and 17/30 (56.7%) in the PET/CT group (P 0.037). Fourteen tumors underwent local retreatment (11 ablations, 2 with resection and 1 with stereotactic body radiation therapy), while 4 tumors could not be retreated because of distant disease progression and underwent systemic therapy. Finally, 54/58 (93.1%) tumors were completely treated at 1 year. One major complication occurred, a gastrointestinal hemorrhage which required surgical repair.Percutaneous ablation of

BACKGROUND Most of the studies on peripheral artery disease (PAD) focused on above-the-ankle artery disease, while less is known about foot artery disease. We hypothesize a scenario were two different diseases can be present in PAD patients, big artery disease (BAD) and small artery disease (SAD), overlapping at the foot level; the aim of this study is to evaluate their prevalence and their correlation with risk factors and critical limb ischemia (CLI) in a large cohort of patients with symptomatic PAD. METHODS We retrospectively reviewed 1915 limbs of 1613 patients (502 females, mean age 72.4±10.8 years) who underwent angiography between September 2009 and November 2013. Age, sex, diabetes, smoke history, high blood pressure, dialysis and BMI were considered as risk factors. Logistic regression was performed to test the association of arterial lesions patterns and CLI, and to evaluate the association between risk factors and lesion localization. RESULTS SAD was present in 414 patients (25.2%). Patients with disease of any of plantar, dorsalis pedis arteries and SAD faced higher risk of CLI (OR=13.25, 95% CI: 1.69-104.16). SAD was associated with diabetes and dialysis (both: OR=4.85; dialysis only: OR=3.60; diabetes only: OR=1.70; none: reference OR; P

The aim of this retrospective study was to assess the safety and effectiveness of laser ablation (LA) in patients with small renal cell carcinomas (RCC) and increased risk of bleeding.From 2013 to 2017, nine patients (six males, three females, aged 68.5 ± 12.2 years) at high risk of bleeding underwent ultrasonography-guided LA for an RCC. Patients were considered at increased risk of bleeding because of impairment of coagulation parameters, concomitant antiplatelet therapy, or at-risk location of the tumor (one, five, and three patients, respectively). RCC diameter ranged from 11 to 23 mm. According to tumor size, two or three laser fibers were introduced through 21-gauge needles and 1800 J per fiber were delivered in 6 min with a fixed power of 5 W. Major and minor complications, technical success, and primary and secondary technical effectiveness and tumor recurrence were recorded.Just one Grade 1 complication was observed: a small asymptomatic hematoma that spontaneously resolved. Technical success was 100%, 1 month technical efficacy was 88.9% (8/9 patients). One patient with residual tumor was successfully retreated 1 month later, and secondary efficacy rate was 100%. No local tumor recurrence occurred during a median follow-up of 26 months (range 11-49 months).LA is safe and effective in the treatment of small RCC and might represent a valid option in patients with increased risk of bleeding.

During the last few decades, a new approach to the nonsurgical management of thyroid nodular disease was proposed and thoroughly assessed. Presently several centres in different parts of the world ...

Osteoporosis is the most important metabolic bone disease, with a wide distribution among the elderly. It is characterized by low bone mass and micro architectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk. Identify bone weakening with an appropriate and accurate use of diagnostic imaging is of critical importance in the diagnosis and follow-up of osteoporotic patients. The aim of this review is to evaluate the detection rates of the different imaging modalities in the evaluation of bone strength, in the assessment of fracture risk and in the management of fragility fractures. (www.actabiomedica.it)

Image-guided laser ablation therapy (LAT) of benign thyroid nodules demonstrated favorable results in randomized trials with fixed modalities of treatment. The aim of this retrospective multicenter study was to assess the effectiveness, tolerability, and complications of LAT in a large consecutive series of patients from centers using this technique in their routine clinical activity.Clinical records of 1534 consecutive laser-treated nodules in 1531 patients from eight Italian thyroid referral centers were assessed. Inclusion criteria were as follows: solid or mixed nodules with fluid component up to 40%; benign cytological findings; and normal thyroid function.LAT was performed with a fixed-power protocol, whereas the number of applicators and illumination times were different according to target size. From one to three illuminations with pullback technique and with a total energy delivery based on the nodule volume were performed during the same session. Patients were evaluated during LAT, within 30 days, and 12 months after the procedure.Total number of treatments was 1837; 1280 (83%) of nodules had a single LAT session. Mean nodule volume decreased from 27 ± 24 mL at baseline to 8 ± 8 mL 12 months after treatment (P.001). Mean nodule volume reduction was 72% ± 11% (range 48%-96%). This figure was significantly greater in mixed nodules (79% ± 7%; range 70%-92%) because they were drained immediately before laser illumination. Symptoms improved from 49% to 10% of cases (P.001) and evidence of cosmetic signs from 86% to 8% of cases (P.001). Seventeen complications (0.9%) were registered. Eight patients (0.5%) experienced transitory voice changes that completely resolved at the ear-nose-throat examination within 2-84 days. Nine minor complications (0.5%) were reported. No changes in thyroid function or autoimmunity were observed.Real practice confirmed LAT as a clinically effective, reproducible, and rapid outpatient procedure. Treatments were well tolerated and risk of major complications was very low.

To evaluate the clinical impact of CT scan in modifying the clinical management in patients referred to the emergency department. We prospectively evaluated 300 patients (177 males, 63 ± 18 years old) admitted in the emergency department (ED) of a single institution, who underwent a CT examination for thoracic and/or abdominal complains. Demographic and clinical data were collected. Hypothesized outcome prior to CT scan and final management (i.e., discharge, short observation in the ED, hospitalization, and department of admission) were compared. After CT examination, a major variation in diagnosis occurred in 37% of cases and clinical management changed in 43%, occurring in 51% of patients who underwent abdominal CT, in 40% of chest CT, and in 29% of chest/abdominal CT (P = 0.015). Department of hospitalization changed in 26% of cases (P

Purpose: To compare contrast material enhancement of glioblastoma multiforme (GBM) with intraoperative contrast-enhanced ultrasonography (US) versus that with preoperative gadolinium- enhanced T1-weighted magnetic resonance (MR) imaging by using real-time fusion imaging. Materials and Methods: Ten patients with GBM were retrospectively identified by using routinely collected, anonymized data. Navigated contrastenhanced US was performed after intravenous administration of contrast material before tumor resection. All patients underwent tumor excision with navigated intraoperative US guidance with use of fusion imaging between real-time intraoperative US and preoperative MR imaging. With use of fusion imaging, glioblastoma contrast enhancement at contrast-enhanced US (regarding location, morphologic features, margins, dimensions, and pattern) was compared with that at gadolinium-enhanced T1-weighted MR imaging. Results: Fusion imaging for virtual navigation enabled matching of realtime contrast-enhanced US scans to corresponding coplanar preoperative gadolinium-enhanced T1-weighted MR images in all cases, with a positional discrepancy of less than 2 mm. Contrast enhancement of gadolinium-enhanced T1-weighted MR imaging and contrast-enhanced US was superimposable in all cases with regard to location, margins, dimensions, and morphologic features. The qualitative analysis of contrast enhancement pattern demonstrated a similar distribution in contrast-enhanced US and gadolinium-enhanced T1-weighted MR imaging in nine patients: Seven lesions showed peripheral inhomogeneous ring enhancement, and two lesions showed a prevalent nodular pattern. In one patient, the contrast enhancement pattern differed between the two modalities: Contrast- enhanced US showed enhancement of the entire bulk of the tumor, whereas gadolinium-enhanced T1-weighted MR imaging demonstrated peripheral contrast enhancement. Conclusion: Glioblastoma contrast enhancement with contrast-enhanced US is superimposable on that provided with preoperative gadolinium- enhanced T1-weighted MR imaging regarding location, margins, morphologic features, and dimensions, with a similar enhancement pattern in most cases. Thus, contrast-enhanced US is of potential use in the surgical management of GBM.

Image-guided ablations are nowadays applied in the treatment of a wide group of diseases and in different organs and regions, and every day interventional radiologists have to face more difficult and unusual cases of tumour ablation. In the present case review, we report four difficult and unusual cases, reporting some tips and tricks for a successful image-guided treatment.

Viscosupplementation (VS) is the intra-articular administration of hyaluronic acid (HA) to treat joint osteoarthritis (OA), with the aim of lubricating intra-articular space and promote viscoinduction. In this article we reviewed the latest scientific evidence on VS for the treatment of symptomatic OA. Despite the use of HA intra-articular injections for treating OA is growing, some controversial aspects about its efficacy and cost-effectiveness remain. Apart for knee, medical evidence is still sparse for most of the joint. These contradictory results from meta-analysis led several international societies to produce guidelines with conflicting recommendations. Whereas HA intra-articular injections are now considered effective and safe for mild to moderate knee OA, its utility in other joint is still questioned and matter of debate. Further prospective studies are warranted for a better understanding of VS clinical and molecular efficacy.

Although the incidence of breast cancer is increasing in the last 10 years, the mortality rate was reduced by 20% due to the earlier tumor diagnosis (more and more frequently nonpalpable intraepithelial neoplasia) and to improved therapies, tailored to each single patient.

Objectives To assess the clinical and the economic impacts of intraprocedural use of contrast-enhanced ultrasound (CEUS) in patients undergoing percutaneous radiofrequency ablation for small (

The authors of this paper declare that their correct family and first names and their correct affiliations are shown in this correction paper.

Percutaneous laser ablation (PLA) may be useful in treating patients with metachronous metastatic lymph nodes in the neck.Our objective was to assess PLA as a treatment of difficult-to-treat metachronous cervical lymph node metastases from papillary thyroid carcinoma.We conducted a retrospective analysis of prospectively collected data at a public hospital.Fifteen patients with previous resection of papillary thyroid carcinoma with elevated serum levels of thyroglobulin (Tg) or anti-Tg antibodies (TgAbs) and 24 metachronous nodal metastases treated between September 2010 and April 2012 were followed with [¹⁸F]fluorodeoxyglucose (¹⁸FDG) positron emission tomography (PET)/computed tomography (CT) and contrast-enhanced ultrasound (CEUS).Intervention was PLA.Technique feasibility and technical success were evaluated. Tg/TgAb serum levels and ¹⁸FDG-PET/CT, and CEUS appearance were assessed at 6 and 12 months and compared with baseline. Complications were recorded.PLA was always feasible, and technical success was achieved in all patients. At 6 months, local control was achieved in 11 of 15 patients (73%), with 6 (40%) having serum Tg/TgAb normalized (P = .017 vs baseline). Whereas 20 of 24 (83%) nodes were negative at ¹⁸FDG-PET/CT and CEUS (P.001 vs baseline), 4 were ¹⁸FDG-PET/CT-positive (3 also CEUS-positive). At the 12-month follow-up, local control was achieved in 10 of 14 patients (71.4%). Sixteen of 20 nodes (80%) were negative at ¹⁸FDG-PET/CT and CEUS (P.001 vs baseline), 4 were ¹⁸FDG-PET/CT-positive (2 also CEUS-positive). Four of 10 (40%) patients had normalization of serum Tg/TgAb (P = .098 vs baseline). No major complications occurred.PLA is potentially feasible, safe, and effective for the treatment of metachronous cervical nodal metastases from papillary thyroid carcinoma. This procedure may reduce or delay a large number of highly invasive repeat neck dissections.

When dealing with pleural or peripheral lung lesions, US guidance is comparable to CT in terms of technical success rate, while allowing for a significant reduction in procedure time and postprocedural pneumothorax and being free from ionizing radiation.

Post-surgical enteric fistula treatment with image-guided percutaneous injection of cyanoacrylic glue G. Mauri *, L.M. Sconfienza , B. Fiore , G. Brambilla , V. Pedicini , D. Poretti , R.F. Lutman , M. Montorsi , F. Sardanelli e a Facolt a di Medicina e Chirurgia, Scuola di Specializzazione in Radiodiagnostica, Universit a degli Studi di Milano, Italy Unit a di Radiologia, IRCCS Policlinico San Donato, Italy Dipartimento di Diagnostica per Immagini, IRCCS Istituto Clinico Humanitas, Italy Dipartimento di Medicina traslazionale, Universita’ degli Studi di Milano, IRCCS Istituto Clinico Humanitas, Rozzano, Italy Dipartimento di Scienze Medico-Chirurgiche, Unit a di Radiologia, Universit a degli Studi di Milano, IRCCS Policlinico San Donato, Milan, Italy

Sir,We read with interest the letter by Tez M. regarding our article recently published in International Journal of Hyperthermia entitled “Benign thyroid nodules treatment using percutaneous laser ...

Benign thyroid nodules are a common disease in the general population. Most often, they are completely asymptomatic and discovered occasionally during routine ultrasound examinations, and do not require any treatment. When thyroid nodules become symptomatic, surgical excision is still considered standard treatment. In the last few years, several experiences in the treatment of benign thyroid nodules through image-guided percutaneous thermal ablation have been reported with encouraging results, so that currently, these treatments are often proposed as first-choice options for patients with symptomatic benign thyroid nodules. In this paper, we discuss the present literature on the topic, focusing on different techniques available for image-guided percutaneous ablation, particularly radiofrequency (RFA), laser (LA), microwave (MWA), and high-intensity-focus ultrasound (HIFU). Little evidence about the efficacy of MWA and HIFU is now available. According to the literature, good results have been obtained with RFA and LA. Regarding RFA, volume reduction after ablative treatment has been found to range from 47 to 84 % at 3–6 months, and from 62 to 93 % at 1 year; LA also seems to be effective in achieving shrinkage of thyroid nodules, with volume reduction from 37 to 81 % at 3–6 months, and from 13 to 82 % at 1-year follow-up. Moreover, applications of advanced image-guidance modality, such as contrast-enhanced ultrasound and virtual navigation with fusion imaging, are discussed.

To evaluate the reduction over time of benign thyroid nodules treated using percutaneous laser ablation (PLA) and radiofrequency ablation (RFA) by the same equipe.Ninety patients (age 55.6 ± 14.1 years) underwent ablation for benign thyroid nodule causing compression/aesthetic dissatisfaction from 2011. Fifty-nine (age 55.8 ± 14.1 years) underwent RFA and 31 (age 55.2 ± 14.2 years) PLA, ultrasound guided. Technical success, complications, duration of ablation and treatment, energy deployed, volumetric percentage reduction at 1, 6 and 12 months were derived. A regression model for longitudinal measurements was used with random intercept and random slope. Values are expressed as mean ± standard deviation or N (%).Technical success was always obtained. No major complications occurred. Mean ablation time was 30.1 ± 13.8 vs. 13.9 ± 5.9 min (p .0001) and mean energy deployment was 5422.3 ± 2484.5 J vs. 34 662.7 ± 15 812.3 J in PLA vs. RFA group. Mean volume reduced from 20.3 ± 16.4 ml to 13.17 ± 10.74 ml (42% ± 17% reduction) at 1st month, 8.7 ± 7.4 ml (60% ± 15% reduction) at 6th month and 7.1 ± 7.7 ml (70%% ± 16% reduction) at 12th month, in PLA group, and from 32.7 ± 19.5 ml to 17.2 ± 12.9 ml (51%±15% reduction) at 1st month, 12.8 ± 9.6 ml (64 ± 14% reduction) at 6th month and 9.9 ± 9.2 ml (74% ± 14% reduction) at 12th month in RFA group. No difference in time course of the relative volume reduction between the two techniques was found.RFA and PLA are similarly feasible, safe and effective in treating benign thyroid nodules when performed by the same equipe. RFA is faster than PLA but require significantly higher energy.

To present the results of our experience with cyanoacrylic glue percutaneous injection to treat post-surgical non-healing enteric fistulae after failure of standard treatments. Eighteen patients (14 males; age range 33–84, mean 69 years) were treated for a non-healing post-surgical enteric fistula after failure of standard treatments. Under computed tomography and/or fluoroscopic guidance, a mixture of cyanoacrylic glue (Glubran 2, GEM, Viareggio, Italy) and ethiodized oil was injected at the site of the fistula. Fistula was considered healed when no material was drained by the percutaneous drainage and a subsequent computed tomography confirmed the disappearance of any fluid collection. In all cases, it was possible to reach the site of the fistula using a percutaneous access. A median of 1 injection (range 1–5) was performed. Fistula healing was achieved in 16/18 (89 %) patients. One patient died for other reasons before fistula healing. Median time for fistula healing was 0 days (mean 8, range 0–58 days). No complications occurred. Reoperation was needed in one patient. Percutaneous injection of cyanoacrylic glue is feasible, safe, and effective to treat non-healing post-surgical enteric fistulae. It may represent a further option to avoid surgical reoperation in frail patients.

Although uncommon, critical hand ischemia (CHI) represents a cause of significant disability because of its effect on hand function. Percutaneous transluminal angioplasty (PTA) is now considered a first-line therapy for above-the-elbow artery disease while there are few data regarding the treatment of below-the-elbow (BTE) arteries. The aim of this study is to review the current literature on BTE vessel PTA and to describe the technical approach. In case of favorable anatomy (absence of inflow arteries disease, standard humeral artery bifurcation), a 4-F antegrade trans-brachial approach is usually the preferred option. Due to the small vessel size and the similarities to coronary and below-the-knee vessels, we consider the BTE vessel treatment as a domain of 0.014" compatible devices. The intraluminal approach is always the preferred technique of guidewire advancement, because the subintimal space in not favorable in BTE vessels. In case of failure of the antegrade approach, retrograde puncture and the radial-ulnar loop technique can be used. Long, low-profile balloons with a diameter between 1.5 and 3.5 mm represent the standard treatment of BTE vessel disease. The use of other devices such as Rotablator, stenting and drug coated balloons has been suggested in very selected cases. Endovascular treatment of BTE vessels is feasible and effective in patients with CHI, with an elevated immediate technical success and satisfactory clinical results.

Critical hand ischemia (CHI) is a not rare condition in patients with end-stage-renal-disease on hemodialysis (HD), and presents devastating consequences due to its impact on life quality. In HD patients CHI may be related to three main conditions: obstruction of the big upper limb arteries, obstruction of the small hand and finger arteries, and the steal effect of a hemodialysis access. The aim of this study was to describe the angiographic pattern of upper limb vascularization and associated cardiovascular risk factors, in a large cohort of consecutive HD patients with CHI studied in our center.In our center 114 HD consecutive patients (age 64±10 years) with a total of 132 upper limbs affected by CHI (21 with rest pain and 93 with tissue loss) underwent angiography in our center. The majority of them were diabetic males. We computed the prevalence of obstructive disease for each vascular segment of the upper limb.Above-the-elbow arteries were mostly spared, while below-the-elbow and hand arteries were extensively affected. We found a stenosis or occlusion in humeral artery (2.3%), radial (61.4%) or ulnar (90.1%) arteries, deep palmar arch (51.5%), superficial palmar arch (58.3%) and digital arteries (72.4%). In 42.4% of cases an ipsilateral functioning arteriovenous fistula was present.CHI in HD patients is a result of below-the-elbow and hand vessel obstruction and is not primarily related to dialysis access.

Critical hand ischemia (CHI) is a quite uncommon but highly disabling condition, generally caused by chronic occlusive arterial disease. For a correct approach to the endovascular treatment of these patients, good knowledge of the normal vascular anatomy and of the most frequently encountered vascular anatomical variations is of paramount importance. In the present paper a description of the normal vascular anatomy of the upper limb and of the most commonly encountered anatomical variations is provided, focusing on the implications for endovascular treatment of patients with CHI. Moreover, data of 151 patients with 172 critically ischemic hands treated at our institution between 2004 and 2016 are presented.