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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3663_Библиотеки_им_академика_М_И_Перельмана
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72 Palliative Cryoablation
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257
Nine IceEdge™ (Boston Scientic, Watertown, MA) needles were placed into the mass extending from the inferior
margin of the ischial tuberosity to the sciatic notch
(Fig.72.1c–e). Cryoablation was performed with two 10-min
ablations with an interval 5-min passive thaw. The ice ball
covered the entire ischial tuberosity during this period with a
9.6 cm maximal diameter. Following the freeze, a 15-min
active thaw was performed. At 1month imaging follow-up,
the mass continued to progress although the debulking procedure improved her pain enough to allow her to sit upright
(Fig.72.1f).
Shockingly Cold: Irreversible
Electroporation andCryoablation
ofPeriportal Nodal andSerosal
Metastases
UeiPua
73
A 73-year-old woman underwent mastectomy for right
breast carcinoma 9 years earlier, with subsequent chemotherapy for lung metastases, liver metastasectomies, and
peripancreatic metastatic nodal resection. She presented
with induced oligometastases with a large 4.5× 4cm periportal lymph node (Fig.73.1, circle) and a 3.8×3.6cm serosal metastasis on the ascending colon (Fig.73.1, arrow).
The periportal lymph node was rst ablated using four
cryoablation probes (IceFORE, Boston Scientic,
Marlborough, MA) under ultrasound and CT guidance
(Fig.73.2). For the serosal metastasis, decision was made to
perform irreversible electroporation (IRE) to the portion of
the tumor adjacent to the bowel loop with a 5mm safety distance (Fig.73.3, curved arrow), followed by cryoablation of
the bulk of the tumor (Fig.73.3, curved arrow)), overlapping
into the IRE ablation zone. Two IRE probes (Nanoknife,
Angiodynamics Inc., Netherlands) were positioned in the
cranio-caudal direction and ablation performed using 3cm
tip exposure with 2000V delivered for 120 pulses. With the
IRE probes left in place as markers. Two cryoablation probes
(ICEFORCE) was then inserted in the bulk of the tumor and
ablation performed with real-time monitoring to ensure ice
ball overlap into the IRE probes but not encroach into the
colon (Fig.73.4 curved arrow and Fig.73.5). The patient was
discharged well with no complications.
Fig. 73.1 Induced oligometastasis, in the form of periportal lymphadenopathy (circle) and serosal metastasis along the ascending colon
(arrow)
Fig. 73.2 CT image of the cryoprobes within the periportal lymph
node with ice ball formation
U. Pua (*)
Department of Diagnostic Radiology, Tan Tock Seng Hospital,
Singapore, Singapore
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR, https://doi.org/10.1007/978-3-031-24251-9_73
258
73 Shockingly Cold: Irreversible Electroporation andCryoablation ofPeriportal Nodal andSerosal Metastases
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 73.5 Photo of the position of the IRE probes (medial and superior,
white arrow) and the cryoablation probes. Note the presence of warm
gauze for skin protection during cryoablation
259
Fig. 73.3 CT image of one of the IRE probes inserted into the serosal
metastasis with 5 mm safety margin from the colonic wall (curved
arrow)
The patient remained well at 24 months with nonenhancement and signicant reduction in size of the periportal lymph node (Fig.73.6, left pre and right 24months) and
near-complete involution of the serosal metastasis (Fig.73.7,
left pre- and right 24 months) save for a subcentimeter
enhancing nodule in the paracolic region which was kept on
surveillance.
Fig. 73.4 CT image of overlap of the ice ball into the IRE probe but
not onto the colonic wall (arrow)
260
Fig. 73.6 CT of the periportal mass (arrows): left (pre-ablation), right (24months), showing non-enhancement with signicant size reduction
U. Pua
73 Shockingly Cold: Irreversible Electroporation andCryoablation ofPeriportal Nodal andSerosal Metastases
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261
Fig. 73.7 CT of the serosal metastasis (arrows): left (pre-ablation), right (24months), showing near-complete involution of the metastasis with a
subcentimeter residual nodule which was kept on surveillance
Iterative Cryoablation ofaHead
andNeck Adenocarcinoma Recurrence
RobertoLuigiCazzato, ChristianDebry, JulienGarnon,
andAfshinGangi
74
A 54-year-old male patient presented with a local adenocarcinoma recurrence of the right maxillary sinus (arrow; Fig.74.1a).
Previous relevant clinical history included three different surgical resections of the right ethmoid bone and one resection of
the sphenoid bone due to a head and neck (H&N) adenocarcinoma, along with two sessions of radiation therapy resulting
into the maximal allowed radiation dose. Given the lack of
chances for further potentially curative (i.e., surgery, radiation
therapy) treatments, salvage cryoablation was offered.
The patient underwent percutaneous CT-guided cryoablation with three different cryo probes (Ice Sphere, Boston Sc).
General anesthesia was used and a double 10-min freezing
cycle was performed, which resulted in an ice ball largely
encompassing the tumor (arrows, Fig.74.1b, c). The patient
ab df
underwent regular MRI follow-up, which allowed the detection of a nodular infra-centimetric enhancement (arrow,
Fig.74.1d), being in favor of a local tumor recurrence in the
ablation zone. A second salvage cryoablation was therefore
performed by applying two cryo probes (Ice Sphere, Boston
Sc) as well as the same ablation protocol used during the rst
cryoablation. A large ice ball well-encompassing the tumor
(arrow, Fig. 74.1e) was created also in this occasion.
Thereafter, the patient continued his regular MRI follow-up,
which showed complete local tumor control 38months after
the rst cryoablation treatment (Fig.74.1f).
Percutaneous cryoablation of H&N tumors has been sporadically reported, and in most of the cases, it has been performed
with a palliative intent. Nevertheless, recent data pointed out a
c
Fig. 74.1 (a) Axial contrast-enhanced T1-weighted MRI demonstrat-
ing the local adenocarcinoma recurrence at the right maxillary sinus
(arrow). (b, c) Axial and sagittal CT images demonstrate the ice ball
forming (arrows) around the multiple cryoprobes encompassing the
tumor. (d) Follow-up axial contrast-enhanced T1-weighted MRI
showing a small enhancing area deemed to represent local recurrence
R. L. Cazzato (*) · J. Garnon · A. Gangi
Department of Interventional Radiology, University Hospital of
Strasbourg, Strasbourg, France
e-mail: RobertoLuigi.CAZZATO@chru-strasbourg.fr
C. Debry
Department of Head and Neck Surgery, University Hospital of
Strasbourg, Strasbourg, France
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR, https://doi.org/10.1007/978-3-031-24251-9_74
e
within the ablation zone (arrow); therefore a second session of cryoablation was organized. (e) Axial CT imaging shows cryoprobes
within the mass during the second cryoablation. The ice ball is visible
as an oval-shaped hypodense zone (arrow). (f) Contrast-enhanced
T1-weighted MRI follow-up (38 months) showed complete local
tumor control
262
74 Iterative Cryoablation ofaHead andNeck Adenocarcinoma Recurrence
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263
local tumor control rate of 45.4% at a mean follow-up of
11.7 months (range 3–34 months), thus revealing a potential
curative role of cryoablation for patients with H&N tumor recurrences having exhausted all the available curative treatments.
Bibliography
1. Gangi A, Cebula H, Cazzato RL, Ramamurthy N, Garnon J, Debry
C, Proust F. “Keeping a Cool Head”: percutaneous imaging-guided
cryo-ablation as salvage therapy for recurrent glioblastoma and
head and neck tumours. Cardiovasc Interv Radiol. 2020;43(2):172–
5. https://doi.org/10.1007/s00270- 019- 02384- 6.
2. Schwartz J, Auloge P, Koch G, Robinson JM, Garnon J, Cazzato
RL, Perruisseau-Carrier J, Debry C, Gangi A. Percutaneous
cryoablation for recurrent head and neck tumors. Cardiovasc
Interv Radiol. 2022;45(6):791–9. https://doi.org/10.1007/
s00270- 022- 03120- 3.
3. Guenette JP, Tuncali K, Himes N, Shyn PB, Lee
TCAJR. Percutaneous image-guided cryoablation of head and
neck tumors for local control, preservation of functional status,
and pain relief. Am J Roentgenol. 2017;208(2):453–8. https://doi.
org/10.2214/AJR.16.16446.
MRI-Guided Cryoablation ofaFrontal
Glioblastoma Recurrence After Surgery
andChemo-Radiotherapy
RobertoLuigiCazzato, HélèneCebula, JulienGarnon,
FrançoisProust, andAfshinGangi
75
A 54-year-old woman presented with a right frontal glioblastoma recurrence (arrow; Fig.75.1a) 18months after primary
surgical resection and chemo-radiotherapy. Due to the lack
of other standard therapeutic options, she was offered compassionate MRI-guided cryoablation. Following surgical
exposure of the tumor under general anesthesia, the patient
was transferred to the 1.5T MRI unit; three ice probes (Ice
Seed, Boston Sc) were directly inserted into the tumor under
MRI-Fluoroscopy. A 10-min freezing cycle was performed
with an ice ball largely encompassing the tumor (arrow,
Fig.75.1b). A surgical necrosectomy of the cryoablated area
was subsequently performed to avoid any massive intracranial edema.
Three-month MRI follow-up demonstrated an enhancing
mass (arrow; Fig. 75.1c) with surrounding edema at the
treated site. A subsequent biopsy revealed necrotic
(Fig. 75.1d) and peri-vascular inammatory (Fig. 75.1e)
changes without any viable tumor. At 5-month follow- up, the
enhancing mass previously seen had signicantly enlarged
(arrow, Fig. 75.1f), and the patient became aphasic.
Surprisingly, at 8-month MRI follow-up, the lesion had
markedly shrunk (arrow, Fig.75.1g) with subsequent resolution of the aphasia; no other concomitant treatments were
used in the meanwhile. Unfortunately, the 12-month MRI
follow-up revealed a focal nodular enhancement at the anterior aspect of the ablation area (arrow, H), which continued
to grow over time, thus being consistent with a local tumor
recurrence. The patient died 2.5years after the cryoablation
due to disease evolution.
Clinical results obtained with this patient were considered encouraging given the actual median overall and
progression- free survivals, respectively, ranging between
5.5 and 12.6 months, and 1.5 months and 4.2 months for
patients with post-surgical/radiotherapy glioblastoma recurrence undergoing further treatments.
R. L. Cazzato (*) · J. Garnon · A. Gangi
Department of Interventional Radiology, University Hospital of
Strasbourg, Strasbourg, France
e-mail: RobertoLuigi.CAZZATO@chru-strasbourg.fr
H. Cebula · F. Proust
Department of Neurosurgery, University Hospital of Strasbourg,
Strasbourg, France
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR, https://doi.org/10.1007/978-3-031-24251-9_75
264
75 MRI-Guided Cryoablation ofaFrontal Glioblastoma Recurrence After Surgery andChemo-Radiotherapy
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265
a
e
b
f
c
g
d
h
Fig. 75.1 (a) Contrast-enhanced axial T1-weighted MRI demon-
strates the right frontal glioblastoma recurrence (arrow). (b) Sagittal
T2-weighted MRI shows the iceball (arrow) encompassing the tumor
during the 10-min freezing cycle. (c) Contrast-enhanced axial
T1-weighted MRI obtained at 3-month follow-up demonstrats an
enhancing mass (arrow) with surrounding edema. (d, e) Histologic
images from a biopsy of the area showed necrotic (d) and peri-vascu-
Bibliography
1. Gangi A, Cebula H, Cazzato RL, Ramamurthy N, Garnon J, Debry
C, Proust F. “Keeping a Cool Head”: percutaneous imaging-guided
cryo-ablation as salvage therapy for recurrent glioblastoma and
head and neck tumours. Cardiovasc Interv Radiol. 2020;43(2):172–
5. https://doi.org/10.1007/s00270- 019- 02384- 6.
2. McBain C, Lawrie TA, Rogozińska E, Kernohan A, Robinson T,
Jefferies S. Treatment options for progression or recurrence of
lar inammatory changes (e) but no viable tumor. (f) At 5-month follow-up, an axial contrast-enhanced T1-weighted MRI revealed
signicant enlargement of the prior mass (arrow). (g) At 8 months,
however, the mass had notably shrunk (arrow). (h) Unfortunately,
12-month follow-up revealed a focal area of enhancing (arrow) at the
anterior edge of the ablation zone, thus being consistent with a local
tumor recurrence
glioblastoma: a network meta-analysis. Cochrane Database Syst
Rev. 2021;5(1):CD013579. https://doi.org/10.1002/14651858.
CD013579.pub2.
3. Cebula H, Garnon J, Todeschi J, Noel G, Lhermitte B, Mallereau
CH, Chibbaro S, Burckel H, Schott R, de Mathelin M, Gangi A,
Proust F. Interventional magnetic-resonance-guided cryotherapy
combined with microsurgery for recurrent glioblastoma: an innovative treatment? Neurochirurgie. 2021;S0028-3770(21):00241–1.
https://doi.org/10.1016/j.neuchi.2021.11.004.
Percutaneous Cryoablation
ofaPrecarious Pulmonary Nodule
AhmadParvinian, PatrickW.Eiken, A.NicholasKurup,
andMatthewR.Callstrom
A 65-year-old woman with a 10-year history of metastatic
colorectal carcinoma presented for percutaneous cryoablation of a 1.3 cm pulmonary metastasis in the medial left
upper lobe (Fig.76.1). The proximity of the nodule to the left
phrenic, vagus, and recurrent laryngeal nerves mandated that
it be displaced from the mediastinum to allow safe ablation
(Fig.76.2).
First, two IceRod Plus cryoprobes (Boston Scientic,
Marlborough, MA, USA) were placed from an anterior
approach to bracket the nodule (Fig.76.3). Then, a Safe-TCentesis catheter (Becton, Dickinson and Company, Franklin
Lakes, NJ, USA) was used to introduce an iatrogenic pneumothorax to lateralize the lung. Unfortunately, pleural adhesions from prior treatments limited the size of the
pneumothorax and the nodule remained too close to the vulnerable nerves to ablate safely (Fig.76.4).
To gain an adequate buffer between the mediastinum and
the planned ablation zone, a 20-gauge spinal needle was used
76
Fig. 76.2 Magnied axial CT image demonstrates the close proximity
of the left upper lobe nodule to the anatomic location of the left phrenic,
vagus, and recurrent laryngeal nerves along the aortic arch (ellipse)
Fig. 76.1 Axial contrast-enhanced computed tomography (CT) image
shows a 1.3cm pulmonary metastasis (arrow) from colorectal carcinoma in the medial left upper lobe
Fig. 76.3 Coronal CT image shows two cryoprobes bracketing the left
A. Parvinian (*) · P. W. Eiken · A. N. Kurup · M. R. Callstrom
Department of Radiology, Mayo Clinic, Rochester, MN, USA
e-mail: parvinian.ahmad@mayo.edu; eiken.patrick@mayo.edu;
kurup.anil@mayo.edu; callstrom.matthew@mayo.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR, https://doi.org/10.1007/978-3-031-24251-9_76
upper lobe nodule (arrow)
266
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