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Background To determine whether artificial intelligence (AI) processed PET/CT images of reduced by one-third of 18-F-FDG activity compared to the standard injected dose, were non-inferior to native scans and if so to assess the potential impact of commercialization. Materials and methods SubtlePET™ AI was introduced in a PET/CT center in Italy. Eligible patients referred for 18F-FDG PET/CT were prospectively enrolled. Administered 18F-FDG was reduced to two-thirds of standard dose. Patients underwent one low-dose CT and two sequential PET scans; “PET-processed” with reduced dose and standard acquisition time, and “PET-native” with an elapsed time to simulate standard acquisition time and dose. PET-processed images were reconstructed using SubtlePET™. PET-native images were defined as the standard of reference. The datasets were anonymized and independently evaluated in random order by four blinded readers. The evaluation included subjective image quality (IQ) assessment, lesion detectability, and assessment of business benefits. Results From February to April 2020, 61 patients were prospectively enrolled. Subjective IQ was not significantly different between datasets (4.62±0.23, p=0.237) for all scanner models, with “almost perfect” inter-reader agreement. There was no significant difference between datasets in lesions’ detectability, target lesion mean SUVmax value, and liver mean SUVmean value (182.75/181.75 [SD:0.71], 9.8/11.4 [SD:1.13], 2.1/1.9 [SD:0.14] respectively). No false-positive lesions were reported in PET-processed examinations. Agreed SubtlePET™ price per examination was 15-20% of FDG savings. Conclusion This is the first real-world study to demonstrate the non-inferiority of AI processed 18F-FDG PET/CT examinations obtained with 66% standard dose and a methodology to define the AI solution price.

Microwave ablation (MWA) has been proposed to suffer less from the heat sink effect compared to radiofrequency ablation but has been reported to cause extension of the ablation zone along intrahepa...

Purpose To compare the size of ablation zones derived from nonperfused ex vivo livers with ablation zones created using an ex vivo perfused porcine liver model. Materials and Methods Six fresh porcine livers were used to evaluate microwave ablation (MWA). Perfused (n = 3) and nonperfused (n = 3) livers were warmed to 37°C by oxygenated, O-positive human blood reconstituted with Ringer solution, using an organ perfusion circuit. During MWA, perfusion was discontinued in the nonperfused group and maintained in the perfused group. After MWA (140 watts × 2 min at 2.45 GHz) with the Acculis MTA System (AngioDynamics, Latham, New York), ablation zones were bisected sagittally. Sections were stained with nicotinamide adenine dinucleotide (NADH) and hematoxylin-eosin to assess viability of cells in ablation and marginal zones. Results Comparison of 22 MWA zones (9 in perfused group, 13 in nonperfused group) was performed. Ablation zones demonstrated a central "white" and peripheral "red" zone. Cells in the white zone were nonviable with no NADH staining. The red zone showed progressive NADH staining toward the periphery, suggesting incomplete cell death. White and red zones of the perfused group were significantly smaller compared with the nonperfused group (short axis, 17.8 mm ± 2.7 vs 21.1 mm ± 3.2, P = .003; long axis, 40.69 mm ± 3.9 vs 39.63 mm ± 5.2, P = .44; intermediate zone,1.33 mm ± 0.04 vs 2.7 mm ± 0.14, P Conclusions MWA algorithms provided by this manufacturer are based on nonperfused organ data, which overestimate ablation zone size. Data from perfused liver models may be required for more accurate dosimetry guidelines.

Purpose: The purpose is to investigate cardiac magnetic resonance and laboratory findings in patients with clinically suspected acute myocarditis and re-assess the evolution of findings in relation to clinical parameters and smoking habits. Methods: We prospectively analyzed 68 consecutive patients (4 females, 64 males, median age 25 years) at baseline and 51 patients 12 months later with regard to age, symptoms, and signs, smoking history, cardiac troponin I, erythrocyte sedimentation rate, c-reactive protein blood levels, electrocardiography changes, and cardiac magnetic resonance findings. Statistical analysis included group comparisons and linear regression between clinical parameters and the obtained data. Results: A statistically significant correlation was recorded between smoking and late gadolinium enhancement extent, both at baseline and follow-up study. Late gadolinium enhancement extent was positively associated with cardiac troponin I serum levels and c-reactive protein and negatively with left ventricular ejection fraction at baseline study. Myocardial segments 4 and 5 were most frequently involved. Late gadolinium enhancement persisted in 96% of patients with no significant extent change at 12-month follow-up, while improved. Conclusions: A strong correlation was recorded between smoking patients with acute myocarditis and extent both at baseline and follow-up cardiac magnetic resonance. Myocardial segments 4 and 5 involvement was most prevalent. Late gadolinium enhancement persisted at follow-up, its incidence was higher than that reported in other studies and did not have an impact on the patient's clinical status or cardiac function. However, longer-term follow-up is highly recommended in these patients.

Purpose Radiation Protection Apparel (RPA) is used during diagnostic imaging and interventional procedures to minimise incidental radiation exposure. The majority of RPA in use are lead-containing, which has until now been considered safe. A recent single-centre study has demonstrated that the external surface of 63 % of RPA was contaminated with lead dust. The purpose of this study was to reproduce this investigation with a larger sample size across Europe and assess whether decontamination procedures were possible. Method The routine RPA Quality Control (QC) process was adapted to include lead dust contamination tests and decontamination if present. The presence of lead dust was determined using a commercially available colorimetric method. RPA that failed initial QC or could not be decontaminated were removed from use. Results From June to October 2019, 728 RPA from 85 imaging centres from five countries underwent initial QC. Of these, 712 were tested for lead dust contamination which was present on 162 (23 %). Following cleaning, 85 (12 %) remained contaminated and were removed from use. Linear regression analysis shows a significant correlation between type of RPA and contamination, (p = 0.0015). There was no correlation between contamination and imaging department, year of manufacture, country and RPA condition (p-values 0.98, 0.90, 0.94 and 0.14 respectively). Conclusions Lead dust contamination is present on 23 % of RPA that would pass routine QC procedures. Approximately half were not amenable to decontamination and were removed from use. Procedures were introduced for the routine handling of RPA, and updated QC steps for assessment and cleaning. Lead-free RPA should be considered.

Background One-third of men may experience biochemical failure by 8 years following radical radiotherapy for localised prostate cancer. Over 90% of men are started on androgen deprivation therapy (ADT) which is non-curative and confers systemic side-effects. Focal salvage therapy (FST) limits collateral tissue damage and may improve therapeutic ratios. In order to deliver FST, distant disease must be ruled-out and intra-prostatic disease must be accurately detected, localised and characterised. Aim FORECAST – Focal Recurrent Assessment and Salvage Treatment – is a study designed to evaluate a novel imaging-based diagnostic and therapeutic complex intervention pathway for men who fail radiotherapy. Methods Men with biochemical failure following radical prostate radiotherapy, prior to salvage therapy will be recruited. They will undergo whole-body multi-parametric MRI (WB-MRI), choline PET/CT, bone-scan and pelvic-mpMRI and then MRI transperineal-targeted biopsies (MRI-TB) and Transperineal Template Prostate Mapping Biopsy (TPM). Those suitable for FST will undergo either high intensity focused ultrasound (HIFU) or cryotherapy. Results Primary outcome measures: a) the accuracy of WB-MRI to detect distant metastatic disease; b) accuracy of prostate mpMRI in local detection of radiorecurrent prostate cancer; c) detection accuracy of MRI-TB; and d) rate of urinary incontinence following FST. Conclusion Focal salvage therapy may confer lower rates of morbidity whilst retaining disease control. In order to deliver FST, intra- and extra-prostatic disease must be detected early and localised accurately. Novel diagnostic techniques including WB-MRI and MRI-TB may improve the detection of distant and local disease whilst reducing healthcare burdens compared with current imaging and biopsy strategies.

Background: Patients with pancreatic cancer have a poor prognosis apart from the few suitable for surgery. Photodynamic therapy (PDT) produces localised tissue necrosis but previous studies using the photosensitiser meso-tetrahydroxyphenylchlorin (mTHPC) caused prolonged skin photosensitivity. This study assessed a shorter acting photosensitiser, verteporfin. Methods: Fifteen inoperable patients with locally advanced cancers were sensitised with 0.4 mg kg−1 verteporfin. After 60–90 min, laser light (690 nm) was delivered via single (13 patients) or multiple (2 patients) fibres positioned percutaneously under computed tomography (CT) guidance, the light dose escalating (initially 5 J, doubling after each three patients) until 12 mm of necrosis was achieved consistently. Results: In all, 12 mm lesions were seen consistently at 40 J, but with considerable variation in necrosis volume (mean volume 3.5 cm3 at 40 J). Minor, self-limiting extrapancreatic effects were seen in multifibre patients. No adverse interactions were seen in patients given chemotherapy or radiotherapy before or after PDT. After PDT, one patient underwent an R0 Whipple's pancreaticoduodenectomy. Conclusions: Verteporfin PDT-induced tumour necrosis in locally advanced pancreatic cancer is feasible and safe. It can be delivered with a much shorter drug light interval and with less photosensitivity than with older compounds.

Dear Editor,We would like to thank Ma et al. for their interest and comments on our study describing perivascular extension of the ablation zone associated with microwave ablation.Ma and colleagues...

We present a case of a patient who following chemotherapy developed semi-invasive pulmonary aspergillosis and an aspergilloma in a lung cavity previously formed by microwave ablation (MWA). A 55-year-old woman presented with cough and shortness of breath after finishing three cycles of chemotherapy for a metastatic nerve sheath tumour. She had been treated by MWA for pulmonary metastases 2 years previously which resulted in a residual right apical lung cavity. Postchemotherapy imaging showed that this cavity had enlarged, developed a thicker wall and contained lobulated soft tissue with a crescent sign on coronal reformats. In addition, the patient9s Aspergillus-specific IgG was markedly raised. Treatment with itraconazole improved the symptoms and reduced the cavity size and wall thickness. This case shows that persisting lung cavities after MWA are a potential site for semi-invasive aspergillosis and has implications for the timing of chemotherapy in patient with metastatic lung disease.

High-intensity focused ultrasound (HIFU) provides a potentially non-invasive alternative to conventional therapies. We have been using the extracorporeal ultrasound-guided Model-JC Tumor Therapy System (HAIFU™ Technology Co, China) in clinical trials to evaluate the safety and feasibility of treating renal and liver tumours. 30 patients have been treated (22 liver and 8 kidney tumours), all of whom were available for adverse event reporting. Of the 22 liver tumours, 20 are evaluable for response to treatment; 14 were followed up with magnetic resonance imaging (MRI) alone, and 6 with both MRI and histological resection. Evidence of ablation was seen in 20/20 (100%) cases radiologically, and 6/6 (100%) cases histologically. Of the 8 kidney tumours treated, 7 are evaluable; 2 were followed up with MRI alone, and 5 with both MRI and histological resection. Evidence of ablation was seen in 4/7 (57%) radiologically and 1/5 (20%) histologically. Mild, moderate or severe transient pain was reported by 16 (53%), 7 (23%) and 1 (3%) patients, respectively. Superficial skin toxicity was seen in 7 patients (23%). Renal function was unaffected, and all patients were fit for discharge from hospital the day after treatment. Early results show that this technique is feasible, and carries a low morbidity. © 2005 American Institute of Physics.

From: Lawrence Best, BSc Beatrice Seddon, PhD, MRCP, FRCR Simon Woldman, MD, FRCP (Glas), FRCP, FESC Alexander Lyon, PhD, MRCP Rowland Illing, DM, MRCS, FRCR University College London Medical School (L.B.) Department of Specialist Imaging (R.I.) Podium Level 2 University College Hospital London NW1 2BU, UK University College London Hospitals NHS Foundation Trust (B.S., S.W.) NIHR Cardiovascular Biomedical Research Unit (A.L.) Royal Brompton Hospital London, United Kingdom

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To determine whether primary extracorporeal high-intensity focused ultrasound (HIFU) is safe, feasible and effective for managing small renal tumours. PATIENTS AND METHODS Although surgery currently remains the standard treatment for localized renal cell carcinoma (RCC), the increasing incidence of small renal cancers has led to a shift towards nephron-sparing surgery, with associated morbidity in 20–25% of cases, and minimally invasive ablative therapies present an alternative management. HIFU results in ‘trackless’ homogenous tissue ablation and when administered via an extracorporeal device, is entirely noninvasive. The study comprised 17 patients (mean tumour size 2.5 cm) with radiologically suspicious renal tumours who underwent extracorporeal HIFU using the Model-JC System (Chongqing HAIFUTM, China), under general anaesthesia with one overnight hospital stay. Real-time diagnostic ultrasonography was used for targeting and monitoring. Patients were followed with a clinical review and gadolinium-enhanced magnetic resonance imaging at 12 days and every 6 months for a mean of 36 months. The outcomes measures were patient morbidity and oncological efficacy of HIFU treatment. RESULTS Of the 17 patients, 15 were treated according to protocol; two procedures were abandoned due to intervening bowel. There were no major complications related to HIFU. Radiological evidence of ablation was apparent at 12 days in seven of the 15 patients. Before the 6-month follow-up one patient had surgery due to persisting central enhancement. Fourteen patients were evaluated at the 6-month follow-up; eight tumours had involuted (mean 12% decrease in tumour area). Four patients had irregular enhancement on imaging and had alternative therapies. Ten patients remain on follow-up at a mean (range) of 36 (14–55) months after HIFU (mean 30% decrease in tumour area). There was central loss of enhancement in all. CONCLUSIONS Renal HIFU achieves stable lesions in two-thirds of patients, with minimal morbidity, and might be appropriate in selected cases. Further trials with accurate histological follow-up are essential to fully evaluate this novel technique.

Purpose Working in a dynamic, complex and high workload environment can lead to unintended radiation exposures. Unintended does not mean unable to prevent. Establishing a unified incident management system in an international healthcare services organisation facilitates better identification of safety critical steps. A bigger ‘pool of events’ can identify trends in incident types and maximize improvement opportunities across the whole system. Methods There is never a single cause for an incident to happen. The incident management system of the organization, AIMS, is a tool developed to log and learn from any adverse events that concern patients, staff or third-parties under the organization’s care. AIMS is not designed to be an administrative tool to find and penalise individuals, but to support collective learning within the organization network to prevent failures and avoid harm. AIMS is a digital platform accessible to all personnel to log incidents and good catches; incidents which were prevented, due to timely and competent personnel action. It is purposefully a four click process to promote easy and fast logging of events, including process stage, incident type and severity. Once an event is logged, approval of the information provided is required before investigation and analysis of the root causes that lead to the event are initiated. Results AIMS allows the process stage to be logged – that is, the stage in the journey at which the event occurred. In-depth investigation identifies failures in the often-complex healthcare environment, allows detection of risks and developing ways to reduce or eliminate the risk of reoccurrence. Good catches and incidents of moderate and above severity are shared with the group regularly as a learning process. Root cause analysis of events allows scrutiny of the preceding process stages, in order to identify contributory factors leading up to the event and definition of actions. Conclusions To Err is Human. We cannot change the human condition, but we can change the condition under which humans’ work. Incident management is a valuable tool to promote a safety culture and awareness through the involvement of and feedback to staff and managers.

Purpose: To prospectively evaluate magnetic resonance (MR) imaging findings after high-intensity focused ultrasound (HIFU) treatment of the prostate and to correlate them with clinical and histologic findings.Materials and Methods: Local ethics committee approval and informed consent were obtained. Fifteen consecutive men aged 46-70 years with organ-confined prostate cancer underwent ultrasonographically guided ablation of the whole prostate. Postoperative MR images were obtained within 1 month (12 patients), at 1-3 months (five patients), and in all patients at 6 months. Prostate volume was measured on T2-weighted images, and enhancing tissue was measured on dynamic images after intravenous administration of gadopentetate dimeglumine. Prostate-specific antigen (PSA) level was measured at regular intervals, and transrectal biopsy was performed in each patient at 6 months after treatment.Results: Initial post-HIFU images showed a central nonenhancing area, surrounded by an enhancing rim. All 6 months, the prostate was small (median volume reduction, 61 %) and was of predominantly low signal intensity oil T2-weighted images. The volume of prostate enhancing oil the initial posttreatment image correlated well with serum PSA level nadir (Spearman r = 0.90, P

OBJECTIVE To assess the extent of scrotal pain in men before and after vasectomy, to produce accurate data for the benefit of men considering this procedure, and hence improved informed consent about the outcomes, as chronic scrotal pain after vasectomy is a poorly quantified clinical problem. PATIENTS AND METHODS Between November 2004 and January 2006 nine surgeons carried out vasectomies in 625 men (mean age 39.9 years, sd 5.6) under local anaesthesia. A questionnaire was devised to establish the presence of any scrotal or testicular pain, and to characterize this discomfort; 6 months after the procedure a modified version of the same questionnaire was administered. RESULTS In all, 593 (94.7%) men returned the preoperative questionnaires and were entered into the study; 488 (82.2%) of these completed the follow-up questionnaire, giving a mean (sd) follow-up of 6.8 (1.6) months. In all, 65 men reported new-onset scrotal pain at 7 months (14.7%). The mean visual analogue score for this pain was 3.4/10. Four men (0.9%) in the responding group described pain after vasectomy as ‘quite severe and noticeably affecting their quality of life’. CONCLUSION At 7 months after vasectomy about 15% of previously asymptomatic men have some degree of scrotal discomfort. These early data indicate that chronic scrotal pain after vasectomy is a genuine entity, but a longer-term follow-up in this group will be important to allow further evaluation of how this pain develops with time.

The current treatment choice for men with localized prostate cancer lies between active surveillance and radical therapy. The difference between these two extremes of care is 5% in terms of cancer-related absolute mortality at 8 years. It is generally accepted that this small difference will decrease for men diagnosed in the prostate-specific-antigen era. Radical therapy is associated with considerable adverse effects (e.g. incontinence, impotence, rectal problems) because it treats the whole gland, and damages surrounding structures in up to half of men. Men are being diagnosed at a younger age with lower-risk disease, and many have unifocal or unilateral disease. We propose a new concept whereby only the tumor focus and a margin of normal tissue are treated. This paradigm might decrease adverse effects whilst, at the same time, retaining effective cancer control. The arguments for and against active surveillance and radical therapy are reviewed in this article, with focal therapy presented as a means for bridging these two approaches.

Objectives This manuscript reviews the strengths and weaknesses of alternatives to transurethral resection of the prostate (TURP) to treat lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH). Methods The majority of data discussed in this paper were presented at the 2006 annual meetings of the European Association of Urology and the American Urological Association. Data from randomised controlled trials (RCTs) comparing surgical interventions for LUTS/BPH versus TURP, from studies including >100 patients and with at least 1 yr of follow-up were included. The participants' opinions on two representative clinical cases were assessed via interactive voting. Results Short-term efficacy of therapy analogues to TURP (bipolar transurethral resection in saline [TURIS], transurethral vaporisation of the prostate [TUVP], and holmium laser resection/enucleation [HoLRP/HoLEP]) seems comparable to TURP, with good safety profiles. Various direct comparative studies show that energy-based ablative techniques (transurethral needle ablation [TUNA], transurethral microwave therapy [TUMT], and photoselective vaporisation of the prostate [PVP]) may be an effective alternative to TURP and are associated with fewer complications. Mechanical stenting seems to be a solution for patients who cannot undergo general anaesthesia. Initial data on the use of botulinum toxin for LUTS/BPH looks promising. However, in all cases, more long-term data (>5 yr of follow-up) are needed to confirm these short-term outcomes. Conclusions Accumulating evidence is reported in favour of several alternatives to TURP. However, in all cases, prospective, long-term RCTs are needed to evaluate if these promising short-term outcomes are sustained over time.

To review the current status of high intensity focused ultrasound (HIFU) therapy in the prostate, in particular the treatment of prostate cancer.Two trans-rectal devices are currently in clinical use; the SonablateR500 and AblathermR. These devices are compared and similarities and differences highlighted.Outcomes from the primary treatment of prostate cancer, and HIFU as a salvage therapy are discussed. The rate of adverse events are described after each of these, and the role and safety of other therapies after primary HIFU failure are outlined. Factors which may influence outcome such as use of neo-adjuvant androgen suppression are discussed.Trans-rectal HIFU for prostate cancer is a promising technique with medium-term oncological results broadly comparable to standard therapies. It is the only form of therapy which is non-invasive and does not utilise ionising radiation. This is an exiciting field undergoing rapid developments, both in the technology and the way in which prostate cancer as a disease is managed.

Purpose To evaluate the safety and efficacy of percutaneous high-energy microwave ablation (MWA) for the treatment for pulmonary tumors. Materials and Methods A retrospective review was undertaken of 44 patients (21 men, 23 women; median age, 66 y; range, 17–89 y) who underwent 62 sessions of high-energy MWA for 87 pulmonary tumors at a single tertiary referral center between June 2012 and June 2014. Primary tumor origin was sarcoma (n = 23), colorectal (n = 16), lung (n = 2), esophageal (n = 1), breast (n = 1), and bladder (n = 1). Median tumor size was 12 mm (range, 6–45 mm). Technical success was recorded contemporaneously, complication rate at 30 days was recorded prospectively, and technique effectiveness was assessed by longitudinal follow-up CT scan. Results Primary technical success was achieved in 94% of ablation sessions. The median follow-up interval was 15 months (range, 6.2–29.5 mo) during which time local tumor progression was observed in two of 87 tumors (technique effectiveness 98%). Pneumothorax requiring chest tube insertion occurred in 19%; delayed pneumothorax occurred in four patients. No hemoptysis, infection, or other complications were recorded. Conclusions High-energy MWA is safe and effective for the destruction of lung tumors.

OBJECTIVE To propose a standard for the conduct of visually directed transrectal high-intensity focused ultrasound (HIFU) and to offer a formal description of the changes observed on B-mode ultrasonography (US) during this procedure. We describe our early experience of using two different treatment methods; algorithm-based HIFU and visually directed HIFU for the treatment of organ-confined prostate cancer. PATIENTS AND METHODS Between November 2004 and October 2005, 34 men were treated using the Sonablate®-500 (Focus Surgery, Indianapolis, IN, USA) as primary therapy for T1 or T2 prostate cancer. None had had previous hormone therapy and all had ≥ 3-month PSA nadirs recorded at the follow-up. Nine men were treated using an algorithm-based protocol (group 1) and 25 using visually directed therapy (group 2). The conduct of visually directed treatment was described and changes seen using B-mode US were categorized using three ‘Uchida’ grades. RESULTS The mean PSA nadir achieved in group 2 was 0.15 ng/mL, vs 1.51 ng/mL in group 1 (P

Prostate cancer (PCa) is the most common cancer in men and the second leading cause of death from malignancy in the UK. The number of men diagnosed with PCa is increasing, due in part to an increased willingness of men to visit their family doctors with lower urinary tract symptoms, and also a willingness of physicians to test for it. As the demographic of men diagnosed with PCa becomes younger and better informed, so the demand for a less-invasive alternative to standard therapies becomes greater. The Sonablate-500 is one of only two high-intensity focused ultrasound (HIFU) devices commercially available to treat PCa. HIFU is an attractive treatment option as it is the only form of therapy that neither involves direct instrumentation of the prostate nor ionizing radiation. This article describes the unique features of both the Sonablate-500 system hardware and software, and the outcome data from this device in the context of current standard therapies. Finally, a view into the future attempts to outline where this technology is heading and how a paradigm shift in the way that PCa is considered may make HIFU even more relevant.

ObjectiveTo map out the current provision of interventional oncology (IO) services in the UK.DesignCross-sectional multicentre study.SettingAll National Health Service (NHS) trusts in England and Scottish, Welsh and Northern Ireland health boards.ParticipantsInterventional radiology (IR) departments in all NHS trusts/health boards in the UK.ResultsA total of 179 NHS trusts/health boards were contacted. We received a 100% response rate. Only 19 (11%) institutions had an IO lead. 144 trusts (80%) provided IO services or had a formal pathway of referral in place for patients to a recipient trust. 21 trusts (12%) had plans to provide an IO service or formal referral pathway in the next 12 months only. 14 trusts (8%) did not have a pathway of referral and no plans to implement one. 70 trusts (39%) offered supportive and disease-modifying procedures. One trust had a formal referral pathway for supportive procedures. 73 trusts (41%) provided only supportive procedures (diagnostic or therapeutic). Of these, 43 (59%) had a referral pathway for disease-modifying IO procedures, either from a regional cancer network or through IR networks and 30 trusts (41%) did not have a referral pathway for disease-modifying procedures.ConclusionThe provision of IO services in the UK is promising; however, collaborative networks are necessary to ensure disease-modifying IO procedures are made accessible to all patients and to facilitate larger registry data for research with commissioning of new services.

OBJECTIVE To report on the high rectal fistula rate associated with salvage high-intensity focused ultrasound (HIFU) after the failure of combined brachytherapy and external beam radiotherapy (EBRT) for prostate cancer; salvage ablative therapy for prostate cancer is indicated when there is local recurrence after RT, brachytherapy or their combination. PATIENTS AND METHODS We retrospectively reviewed all men with prostate cancer treated with HIFU between 1 March 2005 and 31 May 2007, and identified five men treated after the failure of both brachytherapy and EBRT for localized prostate cancer. RESULTS Three of the five men had iodine-seed implantation brachytherapy combined with EBRT as primary treatment, one had high-dose rate brachytherapy combined with EBRT and one had salvage iodine-seed brachytherapy for failed EBRT. Three of the five patients developed a recto-urethral fistula after HIFU. CONCLUSIONS The high rate of recto-urethral fistula formation in this group might reflect an impaired blood supply or HIFU-associated near-field heating of the rectal wall. Tissue viability and healing might affect this group regardless of the salvage method. Careful patient selection and avoidance of rectal diagnostic biopsies might minimize the risk. Emerging ablative therapies regarded as less invasive than traditional therapies must be used with caution.

OBJECTIVES: To assess the safety and feasibility of high-intensity focused ultrasound (HIFU) ablation of liver tumours and to determine whether post-operative MRI correlates with intra-operative imaging. METHODS: 31 patients were recruited into two ethically approved clinical trials (median age 64; mean BMI 26 kg m(-2)). Patients with liver tumours (primary or metastatic) underwent a single HIFU treatment monitored using intra-operative B-mode ultrasound. Follow-up consisted of radiology and histology (surgical trial) or radiology alone (radiology trial). Radiological follow-up was digital subtraction contrast-enhanced MRI. RESULTS: Treatment according to protocol was possible in 30 of 31 patients. One treatment was abandoned because of equipment failure. Transient pain and superficial skin burns were seen in 81% (25/31) and 39% (12/31) of patients, respectively. One moderate skin burn occurred. One patient died prior to radiological follow-up. Radiological evidence of ablation was seen in 93% (27/29) of patients. Ablation accuracy was good in 89% (24/27) of patients. In three patients the zone of ablation lay ≤2 mm outside the tumour. The median cross-sectional area (CSA) of the zone of ablation was 5.0 and 5.1 cm(2) using intra-operative and post-operative imaging, respectively. The mean MRI:B-mode CSA ratio was 1.57 [95% confidence interval (CI)=0.57-2.71]. There was positive correlation between MRI and B-mode CSA (Spearman's r=0.48; 95% CI 0.11-0.73; p=0.011) and the slope of linear regression was significantly non-zero (1.23; 95% CI=0.68-1.77; p

BACKGROUND: Patients with chronic asthma have thicker intrapulmonary airways measured on high resolution computed tomography (HRCT). We determined whether the presence of lower airway bacteria was associated with increased airway wall thickness. METHODS: In 56 patients with stable severe asthma, sputum specimens obtained either spontaneously or after induction with hypertonic saline were cultured for bacteria and thoracic HRCT scans obtained. Wall thickness (WT) and area (WA) expressed as a ratio of airway diameter (D) and total area, respectively, were measured at five levels. RESULTS: Positive bacterial cultures were obtained in 29 patients, with H. influenzae, P. aeruginosa and S. aureus being the commonest strains. Logistic regression analysis showed that this was associated with the duration of asthma and the exacerbations during the past year. In airways > 2 mm, there was no significant difference in WA (67.5 +/- 5.4 vs 66.4 +/- 5.4) and WT/D (21.6 +/- 2.7 vs 21.3 +/- 2.4) between the culture negative versus positive groups. Similarly, in airways (, link_to_OA_fulltext

Hypertrophic osteoarthropathy (HOA) characterised by arthralgia, clubbing and periosteal proliferation of long bones, is rarely encountered in children and adolescents. Whereas in adults over 80% of cases are associated with malignancy, in children the majority of cases are due to non-neoplastic causes such as cystic fibrosis, bilary atresia and congenital heart disease. Up to 5% of adults with lung cancer demonstrate signs of HOA. However, lung cancer is extremely uncommon in children and young people. Here we report a case of lung adenocarcinoma in an 18 year old male associated with HOA present both at diagnosis and at subsequent disease progression.

To determine whether primary extracorporeal high-intensity focused ultrasound (HIFU) is safe, feasible and effective for managing small renal tumours.Although surgery currently remains the standard treatment for localized renal cell carcinoma (RCC), the increasing incidence of small renal cancers has led to a shift towards nephron-sparing surgery, with associated morbidity in 20-25% of cases, and minimally invasive ablative therapies present an alternative management. HIFU results in 'trackless' homogenous tissue ablation and when administered via an extracorporeal device, is entirely noninvasive. The study comprised 17 patients (mean tumour size 2.5 cm) with radiologically suspicious renal tumours who underwent extracorporeal HIFU using the Model-JC System (Chongqing HAIFU™, China), under general anaesthesia with one overnight hospital stay. Real-time diagnostic ultrasonography was used for targeting and monitoring. Patients were followed with a clinical review and gadolinium-enhanced magnetic resonance imaging at 12 days and every 6 months for a mean of 36 months. The outcomes measures were patient morbidity and oncological efficacy of HIFU treatment.Of the 17 patients, 15 were treated according to protocol; two procedures were abandoned due to intervening bowel. There were no major complications related to HIFU. Radiological evidence of ablation was apparent at 12 days in seven of the 15 patients. Before the 6-month follow-up one patient had surgery due to persisting central enhancement. Fourteen patients were evaluated at the 6-month follow-up; eight tumours had involuted (mean 12% decrease in tumour area). Four patients had irregular enhancement on imaging and had alternative therapies. Ten patients remain on follow-up at a mean (range) of 36 (14-55) months after HIFU (mean 30% decrease in tumour area). There was central loss of enhancement in all.Renal HIFU achieves stable lesions in two-thirds of patients, with minimal morbidity, and might be appropriate in selected cases. Further trials with accurate histological follow-up are essential to fully evaluate this novel technique.

Background: The use of minimally invasive ablative therapies in localised prostate cancer offer potential for a middle ground between active surveillance and radical therapy. Methods: An analysis of men with organ-confined prostate cancer treated with transrectal whole-gland HIFU (Sonablate 500) between 1 February 2005 and 15 May 2007 was carried out in two centres. Outcome data (side-effects using validated patient questionnaires, biochemical, histology) were evaluated. Results: A total of 172 men were treated under general anaesthetic as day-case procedures with 78% discharged a mean 5 h after treatment. Mean follow-up was 346 days (range 135–759 days). Urethral stricture was significantly lower in those with suprapubic catheter compared with urethral catheters (19.4 vs 40.4%, P=0.005). Antibiotics were given to 23.8% of patients for presumed urinary tract infection and the rate of epididymitis was 7.6%. Potency was maintained in 70% by 12 months, whereas mild stress urinary incontinence (no pads) was reported in 7.0% (12 out of 172) with a further 0.6% (1 out of 172) requiring pads. There was no rectal toxicity and no recto-urethral fistulae. In all, 78.3% achieved a PSA nadir ⩽0.5 μg ml−1 at 12 months, with 57.8% achieving ⩽0.2 μg ml−1. Then, 8 out of 13 were retreated with HIFU, one had salvage external beam radiotherapy and four chose active surveillance for small-volume low-risk disease. Overall, there was no evidence of disease (PSA

The use of MRI in prostate cancer management is controversial and current guidelines underplay its role. Technological advances over the past 5 years, however, demand a re-evaluation of this position. In this article, we propose an increased use of MRI, not only in those with a diagnosis of prostate cancer but also for men before a prostate biopsy. The use of MRI before a biopsy can serve as a triage test in men with raised serum prostate-specific antigen levels, in order to select those for biopsy with significant cancer that requires treatment. This strategy could avoid biopsy, and hence unnecessary treatment, in those with no disease or insignificant cancer. In addition, avoidance of postbiopsy artifact caused by hemorrhage will lead to better local staging accuracy, while determining more accurately the disease burden. This approach could improve risk stratification by selecting those who require adjuvant therapy or dose escalation. Furthermore, MRI evaluation of cancer burden could be important in active surveillance regimens to select those needing intervention.

OBJECTIVES To investigate the use of minimally invasive high-intensity focused ultrasound (HIFU) as a salvage therapy in men with localized prostate cancer recurrence following external beam radiotherapy (EBRT). PATIENTS AND METHODS A review of 31 cases treated using the Sonablate® 500 HIFU device, between 1 February 2005 and 15 May 2007, was carried out. All men had presumed organ-confined, histologically confirmed recurrent prostate adenocarcinoma following EBRT. RESULTS The mean (range) age was 65 (57–80) years with a mean preoperative PSA level of 7.73 (0.20–20) ng/mL. The patients were followed for a mean (range) of 7.4 (3–24) months. Side-effects included stricture or intervention for necrotic tissue in 11 of the 31 patients (36%), urinary tract infection or dysuria syndrome in eight (26%), and urinary incontinence in two (7%). Recto-urethral fistula occurred in two men, although one was due to patient movement due to inadequate anaesthesia, so the ‘true’ rate is 3%. Half of the patients had PSA levels of

We evaluated 409 patients suffering from localized prostate cancer treated with high‐intensity focused ultrasound (HIFU). All patients were followed for at least 12 months after treatment. Biochemical failure was defined according to the criteria recommended by the American Society for Therapeutic Radiology and Oncology Consensus Panel. None of the patients received hormonal or other anticancer therapy before documentation of a biochemical failure. The biochemical disease‐free rates at 5 years in patients with low, intermediate and high risk groups were 93%, 68% and 44%, respectively (p

The current choice for men with localised prostate cancer lies between active surveillance and radical therapy. The best evidence for the difference between these two extremes of care is 5% in terms of cancer‐related absolute mortality at 8 years. It is generally accepted that this small difference will decrease for men diagnosed in the PSA‐era.Therein lays a dilemma for men. If they choose active surveillance they accept anxiety of living with a cancer diagnosis and risk of under‐treatment in the long term. On the other hand, radical therapy carries significant toxicity (incontinence, impotence, rectal problems) because it treats the whole gland and damages surrounding structures in up to half of men. With increasing PSA screening practices men are diagnosed younger with lower risk disease — early stage, lower Gleason grade and lower volume of cancer. Many have unifocal or unilateral disease.We propose a new concept whereby only the tumour focus and a margin of normal tissue is treated. With emerging tec...

combined with a tracking system. The illumination profile of the lightwandshowedanellipse-shaped illumination,withpercentage of remaining light according to the distance from the optical fiber. eff was estimated at 0.705 cm−1. A dedicated software allowed to track the wand’s movements inside the patient’s cavity. The light dose delivered on its surfaces was calculated and displayed in real time on computer tomography images. This system suggests a complete peroperative dosimetry in real time for iPDT in the future.

To explore the association between the prostate-specific antigen (PSA) nadir after transrectal high-intensity focused ultrasound (HIFU) therapy for organ-confined prostate cancer and subsequent treatment failure, as defined by the presence of residual disease at biopsy 6 months after treatment.Between January 1999 and January 2005, 115 patients in a Japanese hospital were treated using a transrectal HIFU system (Sonablate, Focus Surgery, IN, USA) for presumed localized adenocarcinoma of the prostate. All treatments were primary and none of the patients had received hormone therapy. The PSA level was measured at 2-monthly intervals and all patients had a transrectal prostate biopsy taken at 6 months. Multiple logistic regression was used to examine the relationship between PSA nadir and treatment failure, as defined by the presence of disease at biopsy.The PSA nadir was strongly associated with treatment failure (P0.001). Patients with a PSA nadir of 0.0-0.2 ng/mL had a treatment failure rate of only 11% (four of 36), compared to 46% (17 of 37) in patients with a PSA nadir of 0.21-1.00 ng/mL and 48% (20 of 42) with a PSA nadir of1.0 ng/mL. In addition, the PSA nadir was strongly associated with both preoperative PSA level and residual prostate volume.There is a clear and intuitive association between the PSA nadir and the risk of treatment failure after HIFU. These data can be used to predict the risk of residual disease in patients with prostate cancer undergoing HIFU therapy. They can also be used to inform where the target PSA nadir should be set for this novel therapy.

An 80 year old man, well known to the local urology department, called his local veterinary practice one Saturday afternoon. From previous painful experience, he knew he was going into urinary retention. He also knew that a hospital admission would mean that no one would be available to look after his Irish wolfhound. The veterinary practice had promised to look after the dog in such circumstances, but by the time the pair reached the surgery the elderly man was in acute urinary retention. …

High-intensity focused ultrasound (HIFU) provides a potential noninvasive alternative to conventional therapies. We report our preliminary experience from clinical trials designed to evaluate the safety and feasibility of a novel, extracorporeal HIFU device for the treatment of liver and kidney tumours in a Western population. The extracorporeal, ultrasound-guided Model-JC Tumor Therapy System (HAIFU™ Technology Company, China) has been used to treat 30 patients according to four trial protocols. Patients with hepatic or renal tumours underwent a single therapeutic HIFU session under general anaesthesia. Magnetic resonance imaging 12 days after treatment provided assessment of response. The patients were subdivided into those followed up with further imaging alone or those undergoing surgical resection of their tumours, which enabled both radiological and histological assessment. HIFU exposure resulted in discrete zones of ablation in 25 of 27 evaluable patients (93%). Ablation of liver tumours was achieved more consistently than for kidney tumours (100 vs 67%, assessed radiologically). The adverse event profile was favourable when compared to more invasive techniques. HIFU treatment of liver and kidney tumours in a Western population is both safe and feasible. These findings have significant implications for future noninvasive image-guided tumour ablation.

High‐intensity focused ultrasound (HIFU) when used clinically to treat liver and kidney tumours is often directed between the ribs. This paper details the construction of a tissue phantom, incorporating ribs, and its use to assess the clinical safety of HIFU exposures. The prefocal, acoustic side‐lobes of the ultrasonic beam were studied with and without rib interference, and thermocouples used to assess in‐situ temperature changes. The results show that there are implications in regards to the safety of clinical treatment, should the operator be unaware of the characteristics of the transducer being used.

We report the case of an osteoid osteoma in the dorsal talar neck of a healthy long-distance runner, masquerading as anterior ankle impingement syndrome. We discuss the diagnosis and successful treatment using percutaneous CT-guided laser photocoagulation. A concise review of the principles of the management of osteoid osteomas is also presented.