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Image-guided thermal ablation of liver cancer is a well-established treatment for patients with primary or secondary liver tumors. While the safety profile for liver ablations is high, several procedure-related complications can occur. An awareness of the potential complications, their recognition, and management are essential for the interventionist who performs liver ablation. This review will describe some of the most frequently encountered complications associated with image-guided thermal ablation of hepatic malignancies.

To determine the pathologic response of computed tomography-guided percutaneous microwave ablation as bridging therapy for patients with hepatocellular carcinoma awaiting liver transplant, and its subsequent effect on survival. A single-center retrospective analysis was conducted on 62 patients (M:F = 50:12) with mean age of 59.6 years ± 7.2 months (SD). Sixty-four total MWA procedures were performed for hepatocellular carcinomas within Milan criteria as bridging therapy to subsequent orthotopic liver transplant between August 2014 and September 2018. The pathology reports of the explanted livers were reviewed to assess for residual disease. Residual disease was categorized as complete or incomplete necrosis. Patient demographics, tumor/procedural characteristics, and laboratory values were evaluated. Survival from time of ablation and time of transplantation were recorded and compared between cohorts using log rank tests. The mean tumor size was 2.4 cm ± 0.7 cm (SD), (range = 1–4.6 cm). 32 (50%) cases required hydrodissection. Histopathologic necrosis was seen in 66% of cases at time of liver transplantation. Median time to liver transplant post-MWA was 12.6 months. [IQR = 8.6–14.8 months]. The median survival from ablation was 60.8 months [IQR = 45.5–73.7 months], and the median survival from transplant was 49.3 months [IQR = 33.7–60.1 months]. There was no significant difference in survival for patients with complete versus incomplete necrosis from ablation or liver transplant (p = 0.49, p = 0.46, respectively). Computed tomography-guided percutaneous microwave ablation is an effective bridge to orthotopic liver transplantation for patients with hepatocellular carcinoma. Level 3, non-randomized controlled cohort study/follow-up study.

BACKGROUND. Obesity is a worldwide problem that impacts patient health as well as the morbidity associated with surgical procedures. Thus, patients with morbid obesity may not be suitable candidates for curative surgery. For this patient population, thermal ablation may be an effective alternative to nephrectomy. OBJECTIVE. The purpose of this study was to determine the feasibility, oncologic outcomes, and survival of patients with morbid obesity and renal cell carcinoma treated with thermal ablation. MATERIALS AND METHODS. A retrospective analysis was performed of 107 patients treated with CT-guided renal ablation for clinical T1 renal cell carcinoma between February 2005 and December 2017. Patients were stratified into two cohorts on body mass index of ≥ 40 kg/m2 (morbidly obese) and body mass index (weight in kilograms divided by the square of height in meters) of ≥ 40 (morbidly obese) and 18.5-24.9 (normal weight). Anesthetic and radiation dosages, procedure time, residual disease, and local recurrence, and adverse events were analyzed between the two groups. Kaplan-Meier statistics were used to evaluate cancer-related outcomes for each group. RESULTS. Thirty-four patients were morbidly obese, and 73 patients had normal weight. Morbid obesity was associated with longer procedural duration (p = .001), sedative doses (p = .002) and radiation exposure (p = .001) than normal weight. Hematomas were more prevalent in patients with morbid obesity than in those of normal weight (p = .01), but treatment efficacy and local recurrences were comparable with those for normal-weight individuals (p = .81 and p = .12, respectively). Cancer-related outcomes were equivalent between the two groups based on 5 years of imaging observation data. CONCLUSION. CT-guided thermal ablation remains technically feasible, well-tolerated, and effective in patients with morbid obesity and renal cell carcinoma, with the caveat of increased risk of perinephric hematoma, anesthesia dose, and radiation exposure. CLINICAL IMPACT. CT-guided thermal ablation can be considered a safe and effective treatment for renal cell carcinoma in patients with morbid obesity.

Purpose To describe interventional oncology therapies combined with immune checkpoint inhibitor (ICI) therapy targeting the programmed death 1 pathway in patients with different neoplasms. Materials and Methods This was a retrospective cohort study of patients who underwent tumor-directed thermal ablation, embolization, or selective internal radiation therapy (SIRT) between January 1, 2011, and May 1, 2019, and received anti–programmed death 1/PD-L1 agents ≤ 90 days before or ≤ 30 days after the interventional procedure. Immune-related adverse events (irAEs) and procedural complications ≤ 90 days after the procedure were graded according to the Common Terminology Criteria for Adverse Events version 5.0. The study included 65 eligible patients (49% female; age 63 years ± 11.1). The most common tumors were metastatic melanoma (n = 28) and non–small cell lung cancer (NSCLC) (n = 12). Patients underwent 78 procedures (12 patients underwent > 1 procedure), most frequently SIRT (35.9%) and cryoablation (28.2%). The most common target organs were liver (46.2%), bone (24.4%), and lung (9.0%). Most patients received ICI monotherapy with pembrolizumab (n = 30), nivolumab (n = 22), and atezolizumab (n = 6); 7 patients received ipilimumab and nivolumab. Results Seven (10.8%) patients experienced an irAE (71.4% grade 1–2), mostly affecting the skin. Median time to irAE was 33 days (interquartile range, 19–38 days). Five irAEs occurred in patients with melanoma, and no irAEs occurred in patients with NSCLC. Management required corticosteroids (n = 3) and immunotherapy discontinuation (n = 1); all irAEs resolved to grade ≤ 1. There were 4 intraprocedural and 32 postprocedural complications (77.8% grade Conclusions No unmanageable or unanticipated toxicities occurred within 90 days after interventional oncology therapies combined with ICIs.

Please see the Editorial Comment by Khashayar Farsad discussing this article. OBJECTIVE. The purpose of this study was to assess the safety, technical results, and clinical outcomes of CT-guided pe...

To identify a patient cohort who received ≥ 100 mSv during a single computed tomography (CT)-guided intervention and analyze clinical information. Using the dose-tracking platform Radimetrics that collects data from all CT scanners in a single hospital, a patient-level search was performed retrospectively by setting a threshold effective dose (E) of 100 mSv for the period from January 2013 to December 2017. Patients who received ≥ 100 mSv in a single day during a single CT-guided intervention were then identified. Procedure types were identified, and medical records were reviewed up to January 2020 to identify patients who developed short- and/or medium-term (up to 8 years) medical consequences. Of 8952 patients with 100 mSv+, there were 33 patients who underwent 37 CT-guided interventions each resulting in ≥ 100 mSv. Procedures included ablations (15), myelograms (8), drainages (7), biopsies (6), and other (1). The dose for individual procedures was 100.2 to 235.5 mSv with mean and median of 125.7 mSv and 111.8 mSv, respectively. Six patients (18 %) were less than 50 years of age. During the study period of 0.2 to 7 years, there were no deterministic or stochastic consequences identified in this study cohort. While infrequent, CT-guided interventions may result in a single procedure dose of ≥ 100 mSv. Awareness of the possibility of such high doses and potential for long-term deleterious effects, especially in younger patients, and consideration of alternative imaging guidance and/or further dose optimization should be strongly considered whenever feasible. • Although not so frequent, CT-guided interventions may result in a single procedure dose of ≥ 100 mSv • Procedures with potential for high dose includes ablations, myelograms, drainages, and biopsies

Thermal ablation of central renal cell carcinoma has been associated with increased risk of incomplete tumor necrosis and adverse events due to the proximity of tumors to the central collecting system and hilar vessels. The purpose of this study was to compare the safety and efficacy of computed tomography-guided percutaneous microwave ablation of central versus peripheral renal cell carcinoma. An institutional database was used to retrospectively identify 114 patients with renal cell carcinoma who were treated with computed tomography-guided percutaneous microwave ablation between January 2015 and December 2019. Patients were divided into two cohorts based on tumor location: central versus peripheral. Central renal tumors were defined as being within 4 mm of renal pelvis and/or ureter and peripheral tumors were defined as tumors beyond 4 mm the renal pelvis and/or ureter. Patient demographics, tumor type, technical success, primary technique efficacy and adverse events were recorded from the medical record. Technical success, primary technique efficacy and adverse events were compared between the two cohorts. There were 44 patients in the central group and 70 patients in the peripheral group. Technical success was 100% for both groups. There was no significant difference in primary technique efficacy rates for peripheral compared to central tumors (93% vs. 89%, p = 0.49). There was no significant difference in overall adverse event rate (17.7% vs. 11.7%, p = 0.34) or Grade II or higher adverse event rate (7.8% vs. 2.6%, p = 0.17) following microwave ablation of central versus peripheral lesions. Adjunctive maneuvers of hydrodissection and/or pyeloperfusion were performed significantly more frequently for treatment for central tumors compared to peripheral tumors (53% vs. 29%, p = 0.006). When adjunctive procedures were utilized more frequently for central compared to peripheral tumors, there was no significant difference in primary technique efficacy or adverse event rate following CT-guided percutaneous microwave ablation of central compared to peripheral renal cell carcinoma. The data suggest that MWA can be successfully applied to select central renal masses and adjunctive maneuvers such as pyeloperfusion should be strongly considered for patient safety. Non-randomized controlled cohort study/follow-up study.

Purpose: To report on the safety, technical results, and oncologic outcomes of computed tomography guided percutaneous microwave ablation of stage cT1b renal cell carcinoma. Materials and Methods: ...

Purpose We present the outcomes of microwave ablation (MWA) of renal cell carcinoma (RCC) with and without pyeloperfusion. Material and methods A retrospective review of patients' records was undertaken to identify patients with RCC, who were treated with MWA with and without adjunctive pyeloperfusion. The distance between the tumour and ureter as well as the tumour size were measured on axial imaging. Pyeloperfusion was performed in nine patients in this series after placement of a ureteral stent and instilment of diluted contrast into the ureter. MWAs of the tumours were performed under computed tomography (CT) guidance. Hydrodissection was performed to displace at-risk organs. Creatinine was measured as renal function index after and before the procedure. A CT scan was performed at the end of the procedure and also after one, three, and six months, to identify the presence of residual disease and complications. Results Eighteen biopsies of proven RCC were treated with 20 sessions of MWA. The average follow-up time for this study was 180 days. The average distance between the ureter and the tumour in axial CT view was 20.8 (± 2.9) mm. Primary efficacy was achieved in 88% of pyeloperfused patients and in 100% of the non-pyeloperfused patients. Two pyeloperfused patients required secondary procedure, and full secondary efficacy was achieved for both. There was only one grade 2 urological complication, which occurred in a patient who underwent pyeloperfusion. Creatinine was not significantly different after the procedure in this study (p-value 0.4). Conclusion In this study MWAs of RCCs were successfully performed using pyeloperfusion as a protective measure against thermal injury to the ureter.

To assess the performance of pre-ablation computed tomography texture features of adrenal metastases to predict post-treatment local progression and survival in patients who underwent ablation using machine learning as a prediction tool. This is a pilot retrospective study of patients with adrenal metastases undergoing ablation. Clinical variables were collected. Thirty-two texture features were extracted from manually segmented adrenal tumors. A univariate cox proportional hazard model was used for prediction of local progression and survival. A linear support vector machine (SVM) learning technique was applied to the texture features and clinical variables, with leave-one-out cross-validation. Receiver operating characteristic analysis and the area under the curve (AUC) were used to assess performance between using clinical variables only versus clinical variables and texture features. Twenty-one patients (61% male, age 64.1 ± 10.3 years) were included. Mean time to local progression was 29.8 months. Five texture features exhibited association with progression (p

Purpose To compare the therapeutic and renal function outcomes of radiofrequency (RF) ablation, cryoablation, and microwave (MW) ablation for treatment of T1a renal cell carcinoma (RCC). Materials and Methods A retrospective assessment of 297 patients (mean age 72 years range 24–90 years) with biopsy-proven RCC treated with image-guided percutaneous thermal ablation was performed between October 2006 and December 2016. Mean tumor size was 2.4 cm; mean radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, hilar tumor touching the main renal artery or vein, and location relative to polar lines; Preoperative Aspects and Dimensions Used for an Anatomical; and c-centrality scores were 6.0, 7.0, and 2.8, respectively. Assessments of adverse events, treatment efficacy, and therapeutic outcomes were performed among RF ablation, cryoablation, and MW ablation. The 2-year disease-free, metastatic-free, and cancer-specific survival rates were tabulated. Estimated glomerular filtration rate was used to assess for treatment related changes in renal function. Results A total of 297 T1aN0M0 biopsy-proven RCCs measuring 1.2–3.9 cm were treated with computed tomography–guided RF ablation (n = 244, 82%), cryoablation (n = 26, 9%), and MW ablation (n = 27, 9%). There were no significant differences in patient demographics among the 3 groups (P = .09). Technical success rates were similar among the 3 treatments (P = .33). Primary efficacy at 1 month postablation was more likely to be achieved with RF ablation and MW ablation than with cryoablation. At 2 years’ follow-up, there was no local recurrence, metastatic progression, or RCC-related death observed in the 3 groups. There was no significant change in estimated glomerular filtration rate among the 3 ablation groups compared with baseline at 2-year follow-up (P = .71). Conclusion RF ablation, cryoablation, and MW ablation are equivalent at 2 years for treatment of T1a RCC for therapeutic outcome, stability of renal function, and low adverse event rate.

Adrenal lesions represent a heterogeneous group of neoplasms that may be benign or malignant. If imaging fails to exclude a lesion as definitely benign or if molecular profiling is required, percutaneous image-guided biopsy may be indicated. When an adrenal lesion requires surgical resection, some patients are found to be too high at surgical risk or some patients may refuse adrenalectomy. Image-guided percutaneous thermal ablation can be an effective alternative – radiofrequency, microwave, and cryoablation have all been described in literature for the successful treatment of adrenal tumors. In this article, technical and clinical factors that reduce the risk of complications, some unique to the adrenal gland, are discussed.

AIMS: Perinephric fat invasion (PFI) is a key component of renal cell carcinoma (RCC) staging, but there are limited data pertaining to biopsy tract seeding (BTS) resulting in perirenal tissue involvement [BTS with perinephric fat invasion (BTS-P)]. The aim is to correlate clinical outcomes with pathologic stage to determine whether the presence of BTS-P should be considered a criterion to stage RCC as part of the pT3a category in the absence of any other upstaging variables. MATERIALS AND RESULTS: We identified 304 renal biopsies from patients with subsequent nephrectomies for RCC; 33 of the tumours contained PFI. Each case was reviewed to determine the presence of BTS-P and other forms of invasion [e.g. non-BTS-P PFI, sinus fat invasion (SFI), and/or renal vein invasion (RVI)], and these findings were compared with survival outcomes. Ten (30%) of 33 tumours with PFI showed BTS-P as the only finding, and were otherwise pT1 tumours; six (60%) patients were alive without disease (AWOD) (mean, 77.5 months), three were lost to follow-up (LTF), and one died of other disease (DOOD). Two patients showed true PFI plus BTS-P; one was LTF and one is AWOD at 107 months. Ten (43%) of 23 patients with tumours with true invasion (PFI ± SFI and/or RVI) are AWOD (mean, 97.7 months), eight (35%) died of disease (DOD), four were LTF, and one DOOD. Kaplan–Meier survival curves showed that the cancer-specific survival was significantly worse in patients with true invasion (P = 0.044) than in those with BTS-P as the sole finding. CONCLUSION: Patients with tumours showing BTS-P only appear to have better outcomes than those with other non-PFI invasion, suggesting that this finding should not be upstaged to pT3a. Additional studies are needed to corroborate the significance of our observations.

To determine the pathologic response of computed tomography-guided percutaneous microwave ablation as bridging therapy for patients with hepatocellular carcinoma awaiting liver transplant, and its subsequent effect on survival.A single-center retrospective analysis was conducted on 62 patients (M:F = 50:12) with mean age of 59.6 years ± 7.2 months (SD). Sixty-four total MWA procedures were performed for hepatocellular carcinomas within Milan criteria as bridging therapy to subsequent orthotopic liver transplant between August 2014 and September 2018. The pathology reports of the explanted livers were reviewed to assess for residual disease. Residual disease was categorized as complete or incomplete necrosis. Patient demographics, tumor/procedural characteristics, and laboratory values were evaluated. Survival from time of ablation and time of transplantation were recorded and compared between cohorts using log rank tests.The mean tumor size was 2.4 cm ± 0.7 cm (SD), (range = 1-4.6 cm). 32 (50%) cases required hydrodissection. Histopathologic necrosis was seen in 66% of cases at time of liver transplantation. Median time to liver transplant post-MWA was 12.6 months. [IQR = 8.6-14.8 months]. The median survival from ablation was 60.8 months [IQR = 45.5-73.7 months], and the median survival from transplant was 49.3 months [IQR = 33.7-60.1 months]. There was no significant difference in survival for patients with complete versus incomplete necrosis from ablation or liver transplant (p = 0.49, p = 0.46, respectively).Computed tomography-guided percutaneous microwave ablation is an effective bridge to orthotopic liver transplantation for patients with hepatocellular carcinoma.Level 3, non-randomized controlled cohort study/follow-up study.

Refractory bile leaks represent a damaging sequela of hepatobiliary surgery and direct trauma. Management of bile leaks represents a challenging clinical problem. Despite advances in endoscopic techniques, interventional radiology continues to play a vital role in the diagnosis and management of refractory bile leaks. This article reviews strategies for optimizing the diagnosis and management of bile leaks and provides an overview of management strategies, including the management of complicated biliary leaks.

This report evaluates the techniques and complications of microwave ablation of cystic renal cell carcinoma. Five patients with cystic renal cell carcinoma were treated with microwave ablation between October 2015 and June 2020. Medical records were reviewed to evaluate technique and complications. Technical success and primary technique efficacy both were 100%. There were no complications. Mean follow-up time was 18 months (range, 6–36 months). No local recurrence was identified during the follow-up period. Renal function remained stable at 1 month and the last follow-up. Percutaneous microwave ablation is promising for the nonsurgical management of cystic renal cell carcinoma.

Ablation techniques are now well-established treatment options available for the management of primary and secondary hepatic malignancies. Currently available ablative techniques include radiofrequency ablation (RFA), microwave ablation (MWA), cryoablation, and irreversible electroporation (IRE). Along with advances in navigational devices and targeting technologies, ablation combined with other therapies may be the next therapeutic option in thermal ablation. The purpose of this review is to evaluate the current status of ablative technologies in interventional and medical oncology for management of liver malignancies. With the use of combination techniques (i.e., ablation and transarterial embolization procedures), thermal ablation is now moving toward treating tumors larger than 3 cm in size or tumors with macrovascular invasion. Ongoing trials are examining the optimum timing of combination therapies. Thermal ablation combined with hepatic resection may increase the number of patients with metastatic colorectal carcinoma to the liver who qualify for curative surgery. Combination therapies of thermal ablation and transarterial embolization allow for promising treatment responses for larger HCC. Surgery combined with thermal ablation can potentially increase the number of patients with metastatic colon cancer to the liver who qualify for curative surgery.

Thermal ablation of central renal cell carcinoma has been associated with increased risk of incomplete tumor necrosis and adverse events due to the proximity of tumors to the central collecting system and hilar vessels. The purpose of this study was to compare the safety and efficacy of computed tomography-guided percutaneous microwave ablation of central versus peripheral renal cell carcinoma.An institutional database was used to retrospectively identify 114 patients with renal cell carcinoma who were treated with computed tomography-guided percutaneous microwave ablation between January 2015 and December 2019. Patients were divided into two cohorts based on tumor location: central versus peripheral. Central renal tumors were defined as being within 4 mm of renal pelvis and/or ureter and peripheral tumors were defined as tumors beyond 4 mm the renal pelvis and/or ureter. Patient demographics, tumor type, technical success, primary technique efficacy and adverse events were recorded from the medical record. Technical success, primary technique efficacy and adverse events were compared between the two cohorts.There were 44 patients in the central group and 70 patients in the peripheral group. Technical success was 100% for both groups. There was no significant difference in primary technique efficacy rates for peripheral compared to central tumors (93% vs. 89%, p = 0.49). There was no significant difference in overall adverse event rate (17.7% vs. 11.7%, p = 0.34) or Grade II or higher adverse event rate (7.8% vs. 2.6%, p = 0.17) following microwave ablation of central versus peripheral lesions. Adjunctive maneuvers of hydrodissection and/or pyeloperfusion were performed significantly more frequently for treatment for central tumors compared to peripheral tumors (53% vs. 29%, p = 0.006).When adjunctive procedures were utilized more frequently for central compared to peripheral tumors, there was no significant difference in primary technique efficacy or adverse event rate following CT-guided percutaneous microwave ablation of central compared to peripheral renal cell carcinoma. The data suggest that MWA can be successfully applied to select central renal masses and adjunctive maneuvers such as pyeloperfusion should be strongly considered for patient safety.Non-randomized controlled cohort study/follow-up study.

To identify a patient cohort who received ≥ 100 mSv during a single computed tomography (CT)-guided intervention and analyze clinical information.Using the dose-tracking platform Radimetrics that collects data from all CT scanners in a single hospital, a patient-level search was performed retrospectively by setting a threshold effective dose (E) of 100 mSv for the period from January 2013 to December 2017. Patients who received ≥ 100 mSv in a single day during a single CT-guided intervention were then identified. Procedure types were identified, and medical records were reviewed up to January 2020 to identify patients who developed short- and/or medium-term (up to 8 years) medical consequences.Of 8952 patients with 100 mSv+, there were 33 patients who underwent 37 CT-guided interventions each resulting in ≥ 100 mSv. Procedures included ablations (15), myelograms (8), drainages (7), biopsies (6), and other (1). The dose for individual procedures was 100.2 to 235.5 mSv with mean and median of 125.7 mSv and 111.8 mSv, respectively. Six patients (18 %) were less than 50 years of age. During the study period of 0.2 to 7 years, there were no deterministic or stochastic consequences identified in this study cohort.While infrequent, CT-guided interventions may result in a single procedure dose of ≥ 100 mSv. Awareness of the possibility of such high doses and potential for long-term deleterious effects, especially in younger patients, and consideration of alternative imaging guidance and/or further dose optimization should be strongly considered whenever feasible.• Although not so frequent, CT-guided interventions may result in a single procedure dose of ≥ 100 mSv • Procedures with potential for high dose includes ablations, myelograms, drainages, and biopsies.

Acute pancreatitis is one of the major gastrointestinal conditions that lead to around 300,000 hospital admissions per year in the United States. While mild inflammation of the pancreas is often managed conservatively, progression of the disease process to necrosis significantly increases the overall morbidity and mortality and often requires surgical or other interventional techniques for management. The purpose of this review is to describe the role of percutaneous drainage for the management of complicated pancreatitis.

Image-guided percutaneous biopsy and abscess drainages are some of the most commonly performed procedures in interventional radiology. With advances in targeted immunotherapies for oncology patients, physicians increasingly depend on the experience and skill of the interventional radiologist to acquire tissue specimens from within the abdomen and pelvis. Furthermore, percutaneous drainage of abdominal and pelvic fluid collections has largely replaced the need for surgical interventions for infected abdominal collections. This review will discuss techniques of image-guided percutaneous abdominal biopsy and drainage.

To assess the feasibility, safety and clinical outcomes of image-guided percutaneous thermal ablation as salvage therapy for local recurrence of renal cell carcinoma (RCC) in patients initially treated surgically with curative intent. A retrospective review of 11 consecutive patients (M/F = 8:3, mean age = 76 years) who underwent computed tomography (CT)-guided thermal ablation for locally recurrent RCC after partial (72%, 8/11) or radical nephrectomy (28%, 3/11) with a mean time to recurrence of 48 months (range 2–156). Assessment of technical success, complication (peri- and post-procedural), oncological outcome and survival analysis were performed. Patient baseline and follow-up renal function surrogates including creatinine level (Cr) and estimated glomerular filtration rate (eGFR) were statistically compared. Eleven biopsy-proven recurrent RCC measuring 1.4–3.9 cm (mean = 2.8 cm) were treated with CT-guided thermal ablation. Technical success was achieved in 100% (11/11) of the cases. There were no major complications except for one (9%) asymptomatic hemorrhage (Clavien–Dindo grade I complication). Complete response, local progression-free and overall survival rate were 91, 91 and 82% during the mean follow-up time of 2.5 years (range 0.1–7.1). Renal function was overall stable without significant change at 1 month and last follow-up (p = 0.21; GFR, p = 0.10; creatinine). Image-guided percutaneous thermal ablation is a feasible, safe and effective for local recurrence after nephrectomy, representing a non-surgical alternative for unresectable disease.

Image-guided thermal ablation is a minimally invasive treatment option for patients with renal cell carcinoma. The purpose of this review is to describe currently available ablation options for renal cell carcinoma and nursing care.

This study assessed radiation dose after CT-guided percutaneous radiofrequency ablations (RFAs) of hepatic and renal tumors and the effect of weight-based CT protocol modification for lowering overall dose in these procedures.CT-guided RFA for renal and hepatic ablations performed from January 1, 2009, through December 31, 2009, were retrospectively reviewed (90 men and 48 women; age, 42-81 years). The radiation dose was recorded during each of the following steps: planning, performing, and postprocedure. Weight-based protocol modification changes in tube voltage and tube current were then applied to renal and hepatic ablations performed subsequently (18 men and 11 women; age, 48-82 years). Image quality, needle localization, lesion detection, ability to detect complications, and overall operator satisfaction were noted for each case (score, 1-5). Dose reduction after modification was then calculated.Retrospective analysis found a mean (± SD) overall CT dose index (CTDI) for CT-guided RFA to be 16.5 ± 2.3 mGy. After protocol modification, the mean CTDI decreased to 6.63 ± 0.67 mGy, a 59.6% reduction overall; for hepatic ablations, the reduction was 65.96% (p0.0001) and the reduction for renal ablations was 38.97% (p = 0.0153). Image quality analysis showed high operator satisfaction (3-5), including adequate needle localization (4-5), lesion visibility (3-5), and high performer confidence (4-5). Higher dose reduction was noted for patients weighing more than 180 lb (82 kg) (p0.0001).Simple weight-based CT protocol modifications can significantly reduce radiation dose during CT-guided percutaneous ablations in the liver and kidneys without significantly sacrificing image quality.

The objective of our study was to assess the technical success, safety, and oncologic and renal function outcomes of CT-guided percutaneous thermal ablation for synchronous multiple renal masses in a single session.A retrospective analysis of 23 patients (16 men and 7 women; median age, 70 years) with biopsy-proven multifocal renal cell carcinoma (RCC) masses treated with radiofrequency ablation (RFA), cryoablation, or microwave ablation (MWA) was performed. Preablation, postablation, and follow-up serum blood urea nitrogen, creatinine, and estimated glomerular filtration rate (GFR) levels were recorded to evaluate the stability of renal function. Technical success, complications, treatment response, oncologic outcome, and overall survival were assessed.Biopsy-proven RCCs were treated in 23 patients. Median tumor size was 2.3 cm (range, 1.0-4.0 cm). The mean RENAL (radius, exophytic vs endophytic properties, nearness of tumor to the collecting system or sinus, anterior vs posterior, location relative to polar lines) nephrometry score was 6.3 (range, 4.0-10.0); mean PADUA (preoperative aspects and dimensions used for anatomical) score, 7.8 (range, 6.0-11.0); and mean centrality index (C-index), 3.1 (range, 0.7-6.8). The mean ablation time was 23 minutes (range, 3-24 minutes). Technical success was achieved for 100% of tumors. Of the 49 complications, nine (18%) were classified as Clavien-Dindo grade I complications. Complete response was achieved in 41 of the 49 (84%) tumors. Local progression-free, RCC-specific disease-free, and overall survival rates during the imaging follow-up time (mean, 3.1 years; range, 0.1-9.6 years) were 96% (22/23), 100% (23/23), and 91% (21/23), respectively.CT-guided percutaneous thermal ablation is a safe, effective, and durable treatment intervention for multifocal renal masses.

The liver is one of the most common sites of metastatic disease from several primary malignancies. While most treatment regimens incorporate a combination of chemotherapy and surgical treatments, ablative techniques are increasingly being used for the treatment of recurrent disease. This article will provide an update on the current status of thermal and nonthermal therapies to treat metastatic liver disease.

This review focuses on the current management of intra-abdominal abscesses that arise from various etiologies. Advances in imaging and percutaneous techniques now lead to image-guided percutaneous drainage as a major factor for the management of intra-abdominal abscesses. In many cases, drainage combined with systemic antibiotic therapy is often all that is necessary for abscess resolution. Emerging surgical techniques now incorporate percutaneous drainage procedures in a stepwise, methodical approach to managing pancreatic necrosis. Image-guided intra-abdominal abscess are a frequent clinical problem encountered in the trauma setting. In most cases, image-guided percutaneous drainage plays a vital role in managing.

Image-guided biopsy and ablation relies on successful identification and targeting of lesions. Currently, image-guided procedures are routinely performed under ultrasound, fluoroscopy, magnetic resonance imaging, or computed tomography (CT) guidance. However, these modalities have their limitations including inadequate visibility of the lesion, lesion or organ or patient motion, compatibility of instruments in an magnetic resonance imaging field, and, for CT and fluoroscopy cases, radiation exposure. Recent advances in technology have resulted in the development of a new generation of navigational guidance tools that can aid in targeting lesions for biopsy or ablations. These navigational guidance tools have evolved from simple hand-held trajectory guidance tools, to electronic needle visualization, to image fusion, to the development of a body global positioning system, to growth in cone-beam CT, and to ablation volume planning. These navigational systems are promising technologies that not only have the potential to improve lesion targeting (thereby increasing diagnostic yield of a biopsy or increasing success of tumor ablation) but also have the potential to decrease radiation exposure to the patient and staff, decrease procedure time, decrease the sedation requirements, and improve patient safety. The purpose of this article is to describe the challenges in current standard image-guided techniques, provide a definition and overview for these next-generation navigational devices, and describe the current limitations of these, still evolving, next-generation navigational guidance tools.

Cross-section imaging plays an increasingly important role in the evaluation and diagnosis of cholangiocarcinoma (CC). CCs can have varied radiological appearances, depending on their location, morphology, as well as their histological characteristics. An awareness of the varied imaging manifestations of CC and its accurate diagnosis are necessary to direct appropriate management. Recent advances in imaging techniques, histological assessment, molecular imaging, surgical techniques, and radiation therapy have all revitalized interest in the diagnosis and management of CCs.

Biliary tract infections cover a wide spectrum of etiologies and clinical presentations. Imaging plays an important role in understanding the etiology and as well as the extent of disease. Imaging also plays a vital role in assessing treatment response once a diagnosis is established. This article will review the imaging findings of commonly encountered biliary tract infectious diseases.

Biliary leaks and bilomas develop due to hepatobiliary surgery, trauma, or locoregional therapy for hepatic malignancies. Though uncommon, they can be a source of abdominal pain, hyperbilirubinemia, and sepsis. A variety of diagnostic tools and interventional techniques are available to diagnose and manage biliary leaks and bilomas. Successful management often requires a multidisciplinary approach between the radiologist, surgeon, and endoscopist.

Cholangiocarcinoma represents the second most common primary hepatic malignancy and carries an overall poor prognosis. While surgical resection offers the only chances for cure, few patients are surgical candidates at the time of diagnosis. Chemotherapeutic treatment with gemcitabine and cisplatin is the standard chemotherapeutic regimen, but this offers only marginal overall survival benefits. With advances in minimally invasive techniques in the past decade, locoregional therapies with thermal ablation and transarterial techniques are increasingly being investigated as treatment options. This review explores emerging technologies and their potential role in treating cholangiocarcinoma.

Biliary strictures are an uncommon yet challenging clinical problem. They are often iatrogenic in nature, usually the consequence of hepatobiliary surgery. Although the etiology may be benign, the clinical consequences, if unrecognized, can progress to ascending cholangitis, sepsis, and hepatic abscesses. Optimal treatment requires expertise and input from multiple specialties, including gastroenterology, surgery, infectious disease, and interventional radiology. Currently, available interventional techniques play a critical role in the management of patients with benign biliary strictures.

Background: Tumoral macrovascular invasion (MVI) of hepatic and/or portal vein branches is a common phenomenon in hepatocellular carcinoma (HCC) and is associated with poorer prognosis when compared to HCC without MVI. Summary: Current international guidelines for the management of HCC recommend sorafenib as the only treatment option in case of MVI. Despite guideline recommendations, several alternative options have been tested to manage HCC with MVI: surgery, transarterial chemoembolization, external or internal radiation, hepatic arterial infusion chemotherapy, percutaneous treatment, cryotherapy, or the combination of two or more of these strategies, with or without sorafenib. Here we will provide a comprehensive state-of-the-art review for the management of this challenging clinical entity based on the most recent available data. Key Messages: There is a growing body of evidence suggesting that alternative strategies to standard-of-care sorafenib might improve survival in patients with advanced HCC with MVI but the level of evidence remains weak. Randomized phase III trials are ongoing and will hopefully provide information leading towards a more personalized treatment algorithm.

ATP-competitive fibroblast growth factor receptor (FGFR) kinase inhibitors, including BGJ398 and Debio 1347, show antitumor activity in patients with intrahepatic cholangiocarcinoma (ICC) harboring activating FGFR2 gene fusions. Unfortunately, acquired resistance develops and is often associated with the emergence of secondary FGFR2 kinase domain mutations. Here, we report that the irreversible pan-FGFR inhibitor TAS-120 demonstrated efficacy in 4 patients with FGFR2 fusion–positive ICC who developed resistance to BGJ398 or Debio 1347. Examination of serial biopsies, circulating tumor DNA (ctDNA), and patient-derived ICC cells revealed that TAS-120 was active against multiple FGFR2 mutations conferring resistance to BGJ398 or Debio 1347. Functional assessment and modeling the clonal outgrowth of individual resistance mutations from polyclonal cell pools mirrored the resistance profiles observed clinically for each inhibitor. Our findings suggest that strategic sequencing of FGFR inhibitors, guided by serial biopsy and ctDNA analysis, may prolong the duration of benefit from FGFR inhibition in patients with FGFR2 fusion–positive ICC.Significance:ATP-competitive FGFR inhibitors (BGJ398, Debio 1347) show efficacy in FGFR2-altered ICC; however, acquired FGFR2 kinase domain mutations cause drug resistance and tumor progression. We demonstrate that the irreversible FGFR inhibitor TAS-120 provides clinical benefit in patients with resistance to BGJ398 or Debio 1347 and overcomes several FGFR2 mutations in ICC models.This article is highlighted in the In This Issue feature, p. 983

This chapter provides a general overview of the common diagnostic imaging findings and optimal use of imaging technologies in the diagnosis, follow-up, and screening of gastrointestinal tract cancers. With the development of state-of-the-art technologies and increased experience with these modalities, imaging is generally the first diagnostic tool employed by physicians in modern medical practice. Imaging modalities such as ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography-computed tomography (PET-CT) can be used in detecting as well as staging of the gastrointestinal cancers.