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OBJECTIVES To analyse the safety, technical feasibility, long-term renal function and oncological outcome of multimodal technologies in image-guided ablation (IGA) for renal cancer in Von-Hippel-Lindau (VHL) patients, and to evaluate factors that may influence the outcome. METHODS Retrospective analysis of a prospective database of VHL patients who underwent IGA at a specialist centre. Patient's demographics, treatment energy, peri-operative outcome and oncological outcomes were recorded. Statistical analysis was performed to determine factors associated with complication and renal function reduction. The overall, 5 and 10-year cancer specific (CS), local recurrence-free (LRF) and metastasis-free (MF) survival rates were presented with Kaplan-Meier Curves. RESULTS From 2004 to 2021, 17 VHL patients (age 21-68.2) with a mean (±SD) RCC size of 2.06 ± 0.92 cm received IGA. Median (IQR) RCCs per patient was 3 (2-4) over the course of follow up. Fifty-four RCCs were treated using radiofrequency ablation (n = 11), cryoablation (n = 38) and irreversible electroporation (n = 8) in 50 sessions. Primary and overall technical success rate were 94.4% (51/54) and 98% (53/54). One CD-III complication with proximal ureteric injury. Five patients in seven treatment sessions experienced a >25% reduction of eGFR immediately post-IGA. All patients have preservation of renal function at a median follow-up of 79 (51-134) months. The 5 and 10-year CS, LRF and MF survival rates are 100%, 97.8% and 100%. Whilst, the 5 and 10-year overall survival rate are100% and 90%. CONCLUSION Multimodal IGA of de novo RCC for VHL patients is safe and has provided long term preservation of renal function and robust oncological durability.

This case discusses the diagnosis, management, and prospect of surveillance for renal oncocytomas. Diagnostic adjuncts such as computed tomography and percutaneous biopsy with histology aim to differentiate these benign renal lesions from the more sinister renal cell carcinomas, particularly chromophobe subtype. There are a number of considerations with each of these diagnostic modalities which contribute to the difficulty of classifying these lesions as benign oncocytomas with certainty. The mainstay of management is still active surgical intervention, which should be nephron-sparing when possible, although surveillance of the lesion is the preferred option for some. Surveillance programmes and triggers to move from active monitoring to surgery are poorly defined and currently largely based on local protocols. Review of cross-sectional imaging prior to renal surgery may reveal important vascular anomalies, including left-sided inferior vena cava as described.

Objectives To evaluate the safety and efficacy of CT-guided IRE of clinical T1a (cT1a) renal tumours close to vital structures and to assess factors that may influence the technical success and early oncological durability. Methods CT-guided IRE (2015–2020) was prospectively evaluated. Patients’ demographics, technical details/success, Clavien-Dindo (CD) classification of complications (I–V) and oncological outcome were collated. Statistical analysis was performed to determine variables associated with complications. The overall 2- and 3-year cancer-specific (CS), local recurrence-free (LRF) and metastasis-free (MF) survival rates are presented using the Kaplan-Meier curves. Results Thirty cT1a RCCs (biopsy-proven/known VHL disease) in 26 patients (age 32–81 years) were treated with IRE. The mean tumour size was 2.5 cm and the median follow-up was 37 months. The primary technical success rate was 73.3%, where 22 RCCs were completely IRE ablated. Seven residual diseases were successfully ablated with cryoablation, achieving an overall technical success rate of 97%. One patient did not have repeat treatment as he died from unexpected stroke at 4-month post-IRE. One patient had CD-III complication with a proximal ureteric injury. Five patients developed > 25% reduction of eGFR immediately post-IRE. All patients have preservation of renal function without the requirement for renal dialysis. The overall 2- and 3-year CS, LRF and MF survival rates are 89%, 96%, 91% and 87%. Conclusion CT-guided IRE in cT1a RCC is safe with acceptable complications. The primary technical success rate was suboptimal due to the early operator’s learning curve, and long-term follow-up is required to validate the IRE oncological durability. Key Points • Irreversible electroporation should only be considered when surgery or image-guided thermal ablation is not an option for small renal cancer. • This non-thermal technique is safe in the treatment of small renal cancer and the primary technical success rate was 73.3%. • This can be used when renal cancer is close to important structure.

Purpose Image-guided thermal ablation are established treatment options for non-surgical patients with primary and metastatic liver cancers. However, there are limitations with nonuniformity of cancer tissue destruction, heat sink effect and the risk of thermal ablative injury. The current non-thermal ablative techniques have high risk of local recurrence and are not widely adopted. Histotripsy is a treatment technology that destroys targeted tissue under ultrasound visualization via mechanical destruction through the precise application of acoustic cavitation and can offer the potential of non-invasive, non-thermal and non-ionizing radiation cancer treatment. The aim of this multi-centre non-randomized phase I/II trial is to assess the initial safety and efficacy of the prototype investigational ‘System’ in the treatment of primary and metastatic liver cancers. Methods/Design All non-surgical patients with primary/metastatic liver cancers having had previous liver directed therapy, radiation therapy or image-guided ablation may be offered image-guided Histotripsy as per trial protocol. The co-primary endpoints are technical success and procedural safety. Technical success is determined, at ≤ 36 h post procedure, by evaluating the histotripsy treatment size and coverage. The procedural safety is defined by procedure related major complications, defined as Common Terminology Criteria for Adverse Events (CTCAE version 5) grade 3 or higher toxicities, up to 30 days post procedure. This phase I/II trial has intended to recruit up to 45 patients to show safety and efficacy of image-guided histotripsy in liver cancers. Trail Registration Clinicaltrials.gov identifier-NCT04573881; NIHR CRN CPMS-ID 47572.

A 69-year-old lady with 2 renal cell carcinomas, one sited at the upper pole of her solitary right kidney, underwent percutaneous image-guided cryoablation and developed urinothorax as a complication. This was diagnosed from pleural fluid analysis and radiology imaging with computed tomography (CT). Management included image-guided chest drain and retrograde ureteric stent insertion to divert the urine from entering the pleural cavity. CT images demonstrated a fistula between the site of renal puncture and the pleural cavity, indicating that the cryoprobes traversed the diaphragm during the procedure. This case highlights urinothorax as an unusual complication of cryoablation of renal cell carcinoma. Prompt diagnosis by interventional radiologists is crucial to avert from this potentially life-threatening complication.

Introduction To evaluate the long-term outcome of image-guided radiofrequency ablation (RFA) when treating histologically confirmed colorectal lung metastasis in terms of overall survival (OS), progression-free survival (PFS) and local tumour control (LTC). Materials and Methods Retrospective single-centre study. Consecutive RFA treatments of histologically proven lung colorectal metastases between 01/01/2008 and 31/12/14. The primary outcome was patient survival (OS and PFS). Secondary outcomes were local tumour progression (LTP) and complications. Prognostic factors associated with OS/ PFS were determined by univariate and multivariate analyses. Results Sixty patients (39 males: 21 females; median age 69 years) and 125 colorectal lung metastases were treated. Eighty percent (n = 48) also underwent lung surgery for lung metastases. Mean metastasis size (cm) was 1.4 ± 0.6 (range 0.3–4.0). Median number of RFA sessions was 1 (1–4). During follow-up (median 45.5 months), 45 patients died (75%). The estimated OS and PFS survival rates at 1, 3, 5, 7, 9 years were 96.7%, 74.7%, 44.1%, 27.5%, 16.3% (median OS, 52 months) and 66.7%, 31.2%, 25.9%, 21.2% and 5.9% (median PFS, 19 months). The LTC rate was 90% with 6 patients developing LTP with 1-, 2-, 3- and 4-year LTP rates of 3.3%, 8.3%, 10.0% and 10.0%. Progression-free interval P = 0.002, HR = 0.375) and total number of pulmonary metastases (≥ 3) treated (P = 0.037, HR = 0.480) were independent negative prognostic factors. Thirty-day mortality rate was 0% with no intra-procedural deaths. Conclusion The long-term OS and PFS following RFA for the treatment of histologically confirmed colorectal lung metastases demonstrate comparable oncological durability to surgery.

There is a lack of cheap and effective biomarkers for the prediction of renal cancer outcomes post-image-guided ablation. This is a retrospective study of patients with localised small renal cell cancer (T1a or T1b) undergoing cryoablation or radiofrequency ablation (RFA) at our institution from 2003 to 2016. A total of 203 patients were included in the analysis. In the multivariable analysis, patients with raised neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) pre-operatively, post-operatively and peri-operatively are associated with significantly worsened cancer-specific survival, overall survival and metastasis-free survival. Furthermore, an increased PLR pre-operatively is also associated with increased odds of a larger than 25% drop in renal function post-operatively. In conclusion, NLR and PLR are effective prognostic factors in predicting oncological outcomes and peri-operative outcomes; however, larger external datasets should be used to validate the findings prior to clinical application.

Objective To compare long-term outcomes and peri-operative outcomes of image-guided ablation (IGA) and laparoscopic partial nephrectomy (LPN). Material and methods This is a retrospective cohort study of localised RCC (T1a/bN0M0) patients undergoing cryoablation (CRYO), radio-frequency ablation (RFA), or LPN at our institution from 2003 to 2016. Oncological outcomes were compared using Cox regression and log-rank analysis. eGFR changes were compared using Kruskal-Wallis and Wilcoxon-rank tests. Results A total of 296 (238 T1a, 58 T1b) consecutive patients were identified; 103, 100, and 93 patients underwent CRYO, RFA, and LPN, respectively. Median follow-up time was 75, 98, and 71 months, respectively. On univariate analysis, all oncological outcomes were comparable amongst CRYO, RFA, and LPN (p > 0.05). On multivariate analysis, T1a patients undergoing RFA had improved local recurrence-free survival (LRFS) (HR 0.002, 95% CI 0.00–0.11, p = 0.003) and metastasis-free survival (HR 0.002, 95% CI 0.00–0.52, p = 0.029) compared to LPN. In T1a and T1b patients combined, both CRYO (HR 0.07, 95% CI 0.01–0.73, p = 0.026) and RFA (HR 0.04, 95% CI 0.03–0.48, p = 0.011) had improved LRFS rates. Patients undergoing CRYO and RFA had a significantly smaller median decrease in eGFR post-operatively compared to LPN (T1a: p < 0.001; T1b: p = 0.047). Limitations include retrospective design and limited statistical power. Conclusions IGA is potentially as good as LPN in oncological durability. IGA preserves kidney function significantly better than LPN. More studies with larger sample size should be performed to establish IGA as a first-line treatment alongside LPN. Key Points • Ablative therapies are alternatives to partial nephrectomy for managing small renal cell carcinomas. • This study reports long-term outcomes of image-guided ablation versus partial nephrectomy. • Ablative therapies have comparable oncological durability and better renal function preservation compared to partial nephrectomy.

INTRODUCTION AND OBJECTIVE:There is a lack of long-term evidence supporting the use of cryoablation (CRYO) and radio-frequency ablation (RFA) when compared to partial nephrectomy (PN) for the manag...

The aim of this manuscript was to establish a consensus for the management of acute and chronic venous obstruction among specialists in the UK. Specialist physicians representing vascular surgery, interventional radiology and hematology were invited to 3 meetings to discuss management of acute and chronic iliofemoral obstruction. The meetings outlined controversial areas, included a topic-by-topic review; and on completion reached a consensus when greater than 80% agreement was reached on each topic. Physicians from 19 UK hospitals agreed on treatment protocols and highlighted areas that need development. Potential standard treatment algorithms were created. It was decided to establish a national registry of venous patients led by representatives from the treating multidisciplinary teams. Technical improvements have facilitated invasive treatment of patients with acute and chronic venous obstruction; however, the evidence guiding treatment is weak. Treatment should be conducted in centers with multi-disciplinary input; robust, coordinated data collection; and regular outcome analysis to ensure safe and effective treatment and a basis for future evolvement.

The quantum dynamics of a particle in a one-dimensional box with an oscillating wall (the Fermi accelerator) is investigated. The model is applied to the motion of a single nucleon in the mean-field potential of a heavy atomic nucleus whose surface vibrates. By directly solving the time-dependent Schrodinger equation, both the state of the particle and its mean-energy are studied. The effects of the frequency of the wall oscillation on the nucleon’s energy are addressed. Its energy oscillates in phase with the moving wall for all frequencies, showing no chaotic behaviour. There is a large initial peak of the nucleon’s energy as the particle adjusts to the sudden change in the size of the box and a varying relaxation time as it plateaus towards lower energy and a partial equilibrium. Small oscillations in energy continue, since there cannot be a true equilibrium while the wall is moving. The quantum coherence between the different parts of the nucleon’s wave-function in real space is very much preserved. This research lays the foundation for future investigations into quantum tunnelling in the Fermi accelerator.

In the introduction section on line 7, the following sentence "A large epidemiological study of colorectal cancer patients with lung metastases found 3 and 5-year survival rates of 1.3% and 6.9%" should actually be "A large epidemiological study of colorectal cancer patients with lung metastases found 3 and 5-year survival rates of 11.3% and 6.9%".

The objective of our study was to investigate whether an increasing number of computer-aided detection (CAD) false-positives decreases reader sensitivity, specificity, and confidence for nonexpert readers of CT colonography (CTC).Fifty CTC data sets (29 men; mean age, 65 years), 25 of which contained 35 polypsor = 5 mm, were selected in which CAD had 100% polyp sensitivity at two sphericity settings (0 and 75) but differed in the number of false-positives. The data sets were read by five readers twice: once at each sphericity setting. Sensitivity, specificity, report time, and confidence before and after second-read CAD were compared using the paired exact and Student's t test, respectively. Receiver operating characteristic (ROC) curves were generated using reader confidence (1-100) in correct case classification (normal or abnormal).CAD generated a mean of 42 (range, 3-118) and 15 (range, 1-36) false-positives at a sphericity of 0 and 75, respectively. CAD at both settings increased per-patient sensitivity from 82% to 87% (p = 0.03) and per-polyp sensitivity by 8% and 10% for a sphericity of 0 and 75, respectively (p0.001). Specificity decreased from 84% to 79% (sphericity 0 and 75, p = 0.03 and 0.07). There was no difference in sensitivity, specificity, or reader confidence between sphericity settings (p = 1.0, 1.0, 0.11, respectively). The area under the ROC curve was 0.78 (95% CI, 0.70-0.86) and 0.77 (0.68-0.85) for a sphericity of 0 and 75, respectively. CAD added a median of 4.4 minutes (interquartile range [IQR], 2.7-6.5 minutes) and 2.2 minutes (IQR, 1.2-4.0 minutes) for a sphericity of 0 and 75, respectively (p0.001). CONCLUSION. CAD has the potential to increase the sensitivity of readers inexperienced with CTC, although specificity may be reduced. An increased number of CAD-generated false-positives does not negate any beneficial effect but does reduce efficiency.

Anatomically, the small intestine comprises the duodenum, jejunum, and ileum and is of variable length (average of 4–6 m). Clinically, the term small intestine usually excludes the duodenum which is covered in Chapter 3. The jejunum refers to the proximal half of the small intestine commencing at the duodenojejunal junction, although there is no clear anatomical distinction between the jejunum and ileum. The jejunum and ileum lie in the free edge of the mesentery. The small bowel mesentery extends from the duodenojejunal junction at the level of the second lumbar vertebra passing diagonally downward to the right sacroiliac joint. The root of the small bowel mesentery measures approximately 15 cm and is situated on the posterior abdominal wall. It contains vessels, lymphatics, and autonomic nerves.

An adolescent male sustained a severe penetrating injury to the external iliac artery. Emergency surgical revascularization was with a reversed long saphenous vein interposition graft. The primary graft and the subsequent revision graft both became aneurysmal. The second graft aneurysm was successfully excluded by endovascular stent-grafts with medium-term primary patency. A venous graft was used initially rather than a synthetic graft to reduce the risk of infection and the potential problems from future growth. Aneurysmal dilatation of venous grafts in children and adolescents is a rare but recognized complication. To the best of our knowledge, exclusion of these aneurysms with stent-grafts has not been previously reported in the adolescent population.

Introduction Metastatic spinal cord compression (MSCC) is a medical emergency, prompt management is required to preserve neurological function. A retrospective audit of MSCC management in the Mid Yorkshire NHS trust in 2012 was conducted. Aims To compare current practice to NICE guidance, and also record patients9 diagnosis, signs, symptoms and three month survival. MRI and radiotherapy time from request were calculated. The prescription of dexamethasone, Low molecular weight heparin (LMWH), analgesia and gastric protection were assessed. Results Twenty seven patients were identified as having MSCC. The most common cancers were lung, prostate and breast, but 15% of patients had no malignant diagnosis at the time of presentation. Most patients had back pain (23), with duration from one day to three months. Fifteen patients had reduced mobility and four patients had bladder dysfunction. Twenty three patients were suspected of having MSCC, three were suspected of having spinal metastasis and one patient was thought to have a slipped disc. Only 53% of the patients with suspected MSCC had an MRI performed within 24 hours. The regional oncology team was contacted in all cases. LMWH and analgesia were given in 96% of the patients. All patients received steroids, but dexamethasone prescribing and dose reduction was inconsistent. Two thirds of patients had radiotherapy within one day. Three month survival was 56%. Conclusion MRI scan within 24 hours was just over 50% and should be 100%; reasons for delay include patients being too unwell to transfer and transport issues, but these were only in a few cases. This is a complex problem, especially if patients are out patients, and requires improved radiology capacity. We recommended staff education and a local protocol, which should include guidelines on standardisation of dexamethasone prescribing. The audit should be repeated once the protocol has been in place for 6–12 months.

The suspected clinical diagnosis often guides the imaging and an investigation may be tailored accordingly. We present a case in which the suspected diagnosis was not confirmed, in order to emphasize the need to consider alternative pathology in that situation.

Introduction Pelvo-ureteric junction obstruction and duplex kidney are common radiological findings. However, pelvo-ureteric junction obstruction in a duplex kidney is a rare finding. We present the case of a patient who presented with septic complications secondary to this combination. Case presentation An adult woman presented with urinary sepsis, and her initial investigation with ultrasound revealed hydronephrosis of the lower moiety of a duplex kidney. Further investigations with computed tomography and magnetic resonance imaging showed an associated intrarenal abscess and a pelvo-ureteric junction obstruction of the lower moiety of a duplex kidney. Conclusion This patient had a rare and unreported complication of an unusual congenital urological abnormality. This case report highlights the role of multiple imaging modalities in correct diagnosis for clinical management.