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BackgroundPercutaneous thermal ablation is an effective, minimally invasive means of treating a variety of focal benign and malignant osseous lesions. To determine the role of ablation in individual cases, multidisciplinary team (MDT) discussion is required to assess the suitability and feasibility of a thermal ablative approach, to select the most appropriate technique and to set the goals of treatment i.e. curative or palliative.PurposeThis document will presume the indication for treatment is clear and approved by the MDT and will define the standards required for the performance of each modality. CIRSE Standards of Practice documents are not intended to impose a standard of clinical patient care, but recommend a reasonable approach to, and best practices for, the performance of thermal ablation of bone tumours.MethodsThe writing group was established by the CIRSE Standards of Practice Committee and consisted of five clinicians with internationally recognised expertise in thermal ablation of bone tumours. The writing group reviewed the existing literature on thermal ablation of bone tumours, performing a pragmatic evidence search using PubMed to search for publications in English and relating to human subjects from 2009 to 2019. Selected studies published in 2020 and 2021 during the course of writing these standards were subsequently included. The final recommendations were formulated through consensus.ResultsRecommendations were produced for the performance of thermal ablation of bone tumours taking into account the biologic behaviour of the tumour and the therapeutic intent of the procedure. Recommendations are provided based on lesion characteristics and thermal modality, for the use of tissue monitoring and protection, and for the appropriately timed application of adjunctive procedures such as osseus consolidation and transarterial embolisation.ResultsPercutaneous thermal ablation has an established role in the successful management of bone lesions, with both curative and palliative intent. This Standards of Practice document provides up-to-date recommendations for the safe performance of thermal ablation of bone tumours.

BackgroundInterventional radiology (IR) has come a long way to a nowadays UEMS-CESMA endorsed clinical specialty. Over the last decades IR became an essential part of modern medicine, delivering minimally invasive patient-focused care.PurposeTo provide principles for delivering high quality of care in IR.MethodsSystematic description of clinical skills, principles of practice, organizational standards and infrastructure needed for the provision of professional IR services.ResultsThere are IR procedures for almost all body parts and organs, covering a broad range of medical conditions. In many cases IR procedures are the mainstay of therapy, e.g. in the treatment of hepatocellular carcinoma. In parallel the specialty moved from the delivery of a procedure towards taking care for a patient’s condition with the interventional radiologists taking ultimate responsibility for the patient’s outcomes. ConclusionsThe evolution from a technical specialty to a clinical specialty goes along with changing demands on how clinical care in IR is provided. The CIRSE Clinical Practice Manual provides interventional radiologist with a starting point for developing his or her IR practice as a clinician.

Purpose To evaluate the technical feasibility and safety of percutaneous cryoablation (CA) for the treatment of single/oligometastatic lymph-node (LN) relapse in different anatomic regions.Materials and MethodsThis is a retrospective study of all patients who underwent percutaneous CA of LN metastases (May 2014–April 2019).ResultsEighteen patients with a total of 27 LNs were treated with CT-guided CA (Galil Medical, Israel). One patient was excluded since no follow-up was available. The mean LN diameter was 11 mm (range 4–28 mm). Thirteen patients had a history of previous treatment for locoregional lymphadenopathy. In 21 LNs, a supplementary thermal insulation-displacement technique was used (hydrodissection = 12; carbodissection = 6; both = 3). According to the RECIST criteria, 8 LNs had a complete response, 8 stable disease, 8 partial response and 1 progressive disease. In the subgroup of patients with prostate cancer relapse, the mean PSA level before treatment was 5.5 ngr/ml (range 0.6–36 ngr/ml) and reduced to 0.32 (range 0–1.1 ngr/ml) and 0.3 (range 0–0.6 ngr/ml) at 3- and 6-month follow-up, respectively. Six patients presented distant tumor deposits on follow-up that were further treated with systemic (5 patients: hormone/chemo/immunotherapy) and local therapies (1 patient: CA of bone oligometastatic disease). No major complication was noted. Two patients with obturator LN presented transient obturator nerve paresis. Mean follow-up was 15 months (range 1–56 months).ConclusionIn this series of patients, we have shown that metastatic LNs can be safely treated with image-guided CA. Caution should be paid, and additional measures should be taken when treating LNs near thermal-sensible structures.

First-line selective internal radiation therapy (SIRT) showed promising outcomes in patients with uveal melanoma liver metastases (UMLM). Patient survival depends on liver’s disease control. SIRT planning is essential and little is known about dosimetry. We investigated whether 99m Tc-MAA-SPECT/CT dosimetry could predict absorbed doses (AD) evaluated on 90 Y-PET/CT and assess the dose–response relationship in UMLM patients treated with first-line SIRT. This IRB-approved, single-center, retrospective analysis (prospectively collected cohort) included 12 patients (median age 63y, range 43–82). Patients underwent MRI/CT, 18 F-FDG-PET/CT before and 3–6 months post-SIRT, and 90 Y-PET/CT immediately post-SIRT. Thirty-two target lesions were included. AD estimates in tumor and non-tumor liver were obtained from 99m Tc-MAA-SPECT/CT and post-SIRT 90 Y-PET/CT, and assessed with Lin’s concordance correlation coefficients ( ρ c and C b ), Pearson’s coefficient correlation ( ρ ), and Bland–Altman analyses (mean difference ± standard deviation; 95% limits-of-agreement (LOA)). Influence of tumor characteristics and microsphere type on AD was analyzed. Tumor response was assessed according to size-based, enhancement-based and metabolic response criteria. Mean target lesion AD was 349 Gy (range 46–1586 Gy). Concordance between 99m Tc-MAA-SPECT/CT and 90 Y-PET/CT tumor dosimetry improved upon dose correction for the recovery coefficient (RC) ( ρ  = 0.725, ρ c  = 0.703, C b  = 0.969) with good agreement (mean difference: − 4.93 ± 218.3 Gy, 95%LOA: − 432.8–422.9). Without RC correction, concordance was better for resin microspheres ( ρ  = 0.85, ρ c  = 0.998, C b  = 0.849) and agreement was very good between predictive 99m Tc-MAA-SPECT/CT and 90 Y-PET/CT dosimetry (mean difference: − 4.05 ± 55.9 Gy; 95%LOA: − 113.7–105.6). After RC correction, 99m Tc-MAA-SPECT/CT dosimetry overestimated AD (− 70.9 ± 158.9 Gy; 95%LOA: − 382.3–240.6). For glass microspheres, concordance markedly improved with RC correction ( ρ  = 0.790, ρ c  = 0.713, C b  = 0.903 vs without correction: ρ  = 0.395, ρ c  = 0.244, C b  = 0.617) and 99m Tc-MAA-SPECT/CT dosimetry underestimated AD (148.9 ± 267.5 Gy; 95%LOA: − 375.4–673.2). For non-tumor liver, concordance was good between 99m Tc-MAA-SPECT/CT and 90 Y-PET/CT dosimetry ( ρ  = 0.942, ρ c  = 0.852, C b  = 0.904). 99m Tc-MAA-SPECT/CT slightly overestimated liver AD for resin (3.4 ± 3.4 Gy) and glass (11.5 ± 13.9 Gy) microspheres. Tumor AD was not correlated with baseline or post-SIRT lesion characteristics and no dose–response threshold could be identified. 99m Tc-MAA-SPECT/CT dosimetry provides good estimates of AD to tumor and non-tumor liver in UMLM patients treated with first-line SIRT.

ObjectiveTo retrospectively assess the safety and oncological efficacy of percutaneous image-guided cryoablation (CA) of T1b (> 4 cm/< 7 cm) renal tumors.Materials and MethodsInstitutional electronic records were retrospectively reviewed to identify the patients who had undergone percutaneous CA of T1b renal tumors between 2008 and 2016. CA was proposed by a multidisciplinary tumor board for cases with poor renal function or a single kidney; unsuitable for surgical resection; or genetic syndromes predisposing to multiple hereditary renal tumors.Patients’ demographics, procedural and follow-up data were accurately collected and analyzed.ResultsTwenty-seven consecutive patients (12 females, 15 males; mean age 72.3 ± 14.3 years) were included. Mean tumor diameter was 47.9 ± 6.3 mm. MRI guidance was used in 6/27 cases (22.2%) and CT guidance in the remaining 21/27 (77.8%) cases. Hydro- and/or carbo-dissections were necessary in 21/27 cases (77.8%). Complications graded ≥ II were reported in three (11.1%) patients. Technical success and technical efficacy were 100 and 87.5%, respectively. Local tumor control (LTC) evaluated at imaging follow-up ≥ 6 months was 82.6, 72.3 and 60.3% at 12-, 24- and 36-month follow-up, respectively. One patient passed away 3 months after CA due to the metastatic evolution of the primary kidney cancer.ConclusionPercutaneous CA of T1b renal tumors is safe and satisfactory rates of LTC are expected at the early follow-ups. Further studies are needed to confirm the long-term efficacy of this procedure.

Purpose We present our experience of utilizing peripheral nerve electrostimulation as a complementary monitoring technique during percutaneous thermal ablation procedures; and we highlight its utility and feasibility in the prevention of iatrogenic neurologic thermal injury. Methods Peripheral motor nerve electrostimulation was performed in 12 patients undergoing percutaneous image-guided thermal ablations of spinal/pelvic lesions in close proximity to the spinal cord and nerve roots. Electrostimulation was used in addition to existing insulation (active warming/cooling with hydrodissection, passive insulation with CO 2 insufflation) and temperature monitoring (thermocouples) techniques. Impending neurologic deficit was defined as a visual reduction of muscle response or need for a stronger electric current to evoke muscle contraction, compared with baseline. Results Significant reduction of the muscle response to electrostimulation was observed in three patients during the ablation, necessitating temporary interruption, followed by injection of warm/cool saline. This resulted in complete recovery of the muscle response in two cases, while for the third patient the response did not improve and the procedure was terminated. No patient experienced postoperative motor deficit. Conclusion Peripheral motor nerve electrostimulation is a simple, easily accessible technique allowing early detection of impending neurologic injury during percutaneous image-guided thermal ablation. It complements existing monitoring techniques and provides a functional assessment along the whole length of the nerve.

Hepatocellular carcinoma (HCC) has the tendency to invade the portal and/or hepatic venous system. The invasion of the right atrium is uncommonly observed and constitutes a treatment challenge. We report the case of a patient with HCC invading the right atrium treated with 90Yttrium-transarterial radioembolization (90Y-TARE). Following the treatment, organizing pneumonia secondary to nivolumab occurred, raising the question of an interaction between 90Y-TARE and nivolumab.

Cryoablation (CA) has gained popularity in the treatment of benign and malignant musculoskeletal tumors. While extra-abdominal desmoid (EAD) tumors are not malignant, they remain challenging to treat because of their high local recurrence rate. We reviewed all EAD tumors treated with CA at our institution between November 2012 and March 2020. Fourteen procedures were performed on nine females and one male (mean age, 33 ± 18 years) as either first-line (n = 4) or salvage therapy (n = 6) with curative intent (n = 8) or tumor debulking (n = 2). Mean tumor size was 63.6 cm3 (range, 3.4–169 cm3). Contrast-enhanced MRI was performed before treatment and at 3-, 6-, and 12-month follow-up. Treatment outcome was based on the change in enhanced tumor volume (ET-V). For curatively treated patients, the mean ET-V change was −97 ± 7%, −44 ± 143%, and +103 ± 312% at 3, 6, and 12 months, respectively. For debulking patients, the mean ET-V change was −98 ± 4%, +149 ± 364%, and +192 ± 353% at 3, 6, and 12 months, respectively. During a mean follow-up of 53.7 months (range, 12–83 months), one grade III and one grade IV complication were noted. We found CA to be safe and well tolerated in patients with EAD.