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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3974_Библиотеки_им_академика_М_И_Перельмана
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176
K. Katsanos and T. Petsas
Patient Preparation and Anesthesia
Obtain informed consent as necessary •
Obtain baseline labs – evaluate for infection or sepsis •
Evaluate platelet count and coagulation parameters. •
Discontinue clopidogrel, aspirin, and NSAIDs as necessary/5–10 days in case of •
neuroaxial procedures
Adhere to strict sterility practice, as in all muskuloskeletal procedures •
Antibiotic prophylaxis with a second- or third-generation cephalosporin. May be •
continued per os after the procedure.
Contraindications
Uncooperative patient •
Uncorrectable coagulopathy •
Inability to safely access the lesion •
Systemic infection or sepsis •
Image Guidance and Lesion Access
Computed tomography (CT) is the imaging method of choice for precise local-•
ization of the OO nidus and accurate guidance during percutaneous thermal abla-
tion. CT has high spatial resolution that is critical for the targeting of
dif fi cult-to-access neuroaxial lesions.
After careful review of the thin-section CT scan, the needle path transversing the •
least thickness of corticol bone must be chosen. In case of long bones, access
from the contralateral side may help stabilize the trocar/needle within the
diaphysis.
Angling of the computed tomography scanner gantry may aid accessibility if •
traditional orthogonal axial views fail to show a safe route of access.
CT fl uoroscopy is an emerging adjunctive tool for high-precision real-time •
guided targeting of subtle lesions. Scanning parameters must be carefully
adjusted to minimize radiation exposure.
Ablation Technique
Thermoablation of OOs was fi rst reported in the early 1990s. •
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14 Ablation of Primary Bone and Soft Tissue Tumors
Intervention is performed under general or spinal anesthesia, because penetra-•
tion and ablation of the OO nidus is extremely painful. Nerve blocks can be used
if the extremities are involved.
Lesion access with a durable bone trocar of appropriate diameter; e.g. 10–15G •
vertebroplasty trocars with diamond- or bevel-shaped needles. Use a sterile ham-
mer to introduce the bone trocar and orientate the bevel of the trocar as necessary
to adjust the needle pathway. Image-guided drilling may be required to gain
access through dense cortical bone.
Once access has been gained, standard bone biopsy is obtained with use of •
appropriate trephine trocars. If possible, sampling of more than one specimen is
encouraged.
Thermoablation with interstitial laser photocoagulation (laser optical fi ber) or •
standard radiofrequency device (nonperfused radiofrequency electrode). Co-axial
insertion of the electrode device through the bone cannula.
After successful placement of the electrode, withdraw the cannula as much as •
possible without displacing the electrode. Direct contact of the metal cannula
with the active electrode tip may overheat the cannula and result in soft tissue
and skin burns.
Radiofrequency ablation parameters: Commercial RF generator, nonperfused •
monopolar electrode, length of active electrode tip 7–10 mm, effective power
<10 W (usually 3–5 W), target temperature 90–95°C, duration of 5–10 min, lim-
ited by vaporization and/or carbonization in case of >100°C.
In case of laser photocoagulation, thermoablation is produced with near-infrared •
wavelengths lasers (neodymium yttrium aluminum garnet Nd:YAG).
Thermal Monitoring and Organ Insulation
Monitoring of local temperature increase is crucial in case of neuroaxial OOs •
with sensitive adjacent anatomical structures, such as the spinal cord and exiting
nerve roots.
One or more thermocouples may be employed for continuous thermal moni-•
toring of the anatomy of interest. Single thermocouples are available as 21G
needles inserted under routine image guidance in proximity with the lesion of
interest.
Thermal insulating techniques like carbon dioxide insuf fl ations may decrease •
heat conductivity between the source electrode and other sensitive organs of
interest. Epidural carbon dioxide infusions have been described.
Whenever applying thermal ablative therapies in the skeleton, beware of the •
electrode being close to metal implants or other metallic osteosynthetic materi-
als, because of their high electrical and heat energy conductance.
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178
K. Katsanos and T. Petsas
Treatment Outcomes
Immediate postprocedural pain may be signi fi cant; NSAIDs and narcotics as •
necessary.
Majority of patients report resolution of pain symptoms after 24–48 h. •
<10% of the patients become symptom-free after 1–2 weeks. •
Reactive sclerosis of the ablated lesions is evident on CT/MR after a period of •
6 months to 2 years.
Overall clinical success rates vary from around 80% to almost 100%. •
Late local recurrence is 5–6%; best treated with repeat thermoablation. •
Complications
Local hematoma. Bleeding or hemorrhage is usually self-limited. •
Synovitis, arthritis, fl uid collection in case of intra-articular OOs •
Neurodystrophia, Sudeck’s atrophy •
Other Bone and Soft Tissue Tumors
Osteoblastomas
Background Facts
Osteoblastomas account for only 0.5–2% of all primary bone tumors and only •
3% of benign bone tumors. Almost 90% of the cases are diagnosed before the
age of 30 years.
Osteoblastomas share the same clinical and histologic manifestations with OOs; •
therefore, some consider the two tumors to be variants of the same disease, with
osteoblastoma representing a giant osteoid osteoma.
Expansile lesions with a sclerotic or shell-like rim. Located in the spine in •
30–40% of the cases, usually af fl ict the posterior spinal elements.
Osteoblastomas may exhibit aggressive behavior and exceed a diameter of 2 cm. •
They may recur after initially successful thermoablation.
The same principles of OO ablation account also for radiofrequency ablation of •
osteoblastomas (Fig. 14.3 ).
Depending on lesion size, electrodes with a longer active tip, needle reposition-•
ing, and multiple ablation sessions may be required. Do not forget bone biopsy
for histological con fi rmation.
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179
14 Ablation of Primary Bone and Soft Tissue Tumors
Chondroblastomas
Chondroblastoma is a rare cartilaginous bone tumor; accounts for 1% of bone •
tumors. It originates from chondroblasts, hence the name.
It is the most common epiphyseal tumor during childhood. It is usually benign •
with a slow-growing nature.
Usually af fl icts the epiphysis of immature long bones prohibiting surgical resec-•
tion. The knee area and proximal humerus are involved in around 70% of the
cases.
The same principles of OO ablation account also for radiofrequency ablation of •
chondroblastomas. Depending on lesion size, needle repositioning and multiple
ablation sessions may be required. Do not forget bone biopsy for histological
con fi rmation. Chondroblastoma must be differentiated from clear-cell
chondrosarcoma.
Only small successful series still reported in the literature. Radiofrequency pro-•
duced heat may damage the nearby joint cartilage and lead to arthritis compro-
mising the joint function.
Other Applications
Radiofrequency ablation has been also successfully applied for the eradication of •
giant cell tumors, enchondromas, eosinophilic granulomas, bone hemangiomas,
Fig. 14.3 Osteoblastoma thermoablation. ( a ) CT-guided insertion of a 10-G beveled bone trocar
to target an osteoblastoma of the sacrum in a 13-year-old female patient suffering from excruciat-
ing pain. The trocar was inserted through the iliac bone and the sacroiliac joint ( fi brous part) to
avoid any damage of the sensitive neurovascular structures. ( b ) Note the co-axial insertion of a
nonperfused RF electrode with a 1-cm long active tip inside the nidus of the lesion. Three ablative
sessions, each 5–10 min long, were delivered with the electrode in slightly different orientations to
cover the whole lesion. Epidural placement of a thermocouple to monitor the temperature around
the adjacent descending sacral roots would be recommended. Pain resolved completely after
1 week and the girl remains free of symptoms for 2 years now
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K. Katsanos and T. Petsas
and intracortical chondromas. However, relevant reports in the literature remain
scarce.
There are isolated reports of radiofrequency ablation of inoperable or unre-•
sectable recurrent tumors like sacral chordomas and soft tissue sarcomas.
However, thermoablation in such extraordinary cases must be part of a multi-
disciplinary treatment protocol encompassing surgery, chemotherapy, and
radiation therapy.
Desmoid tumors are in fi ltrative fi broblastic benign neoplasms that tend to recur •
locally after surgical excision and show poor response to irradiation and chemo-
therapy. Percutaneous chemical or thermal ablative techniques may be ef fi cacious
in the eradication and/or local control of these aggressive tumors.
Although radiofrequency is the leading multipurpose tool for ablation of the •
skeletal system, other technologies such as cryoablation or high-intensity focused
ultrasound (HIFU) may be considered.
Suggested Reading
Gangi A, Tsoumakidou G, Buy X, Quoix E. Quality improvement guidelines for bone tumour
management. Cardiovasc Intervent Radiol. 2010;33(4):706–13.
Kujak JL, Liu PT, Johnson GB, Callstrom MR. Early experience with percutaneous cryoablation
of extra-abdominal desmoid tumors. Skeletal Radiol. 2010;39(2):175–82.
Key Points
OO is a benign skeletal neoplasm of unknown etiology consisting of both •
osteoid and woven bone. It represents 4% of all bone tumors and accounts
for 12% of all benign cases. The lesion is usually smaller than 1.5 cm in
diameter and produces dull or aching pain, worse during the night, typi-
cally relieved by salicylates (Aspirin).
Depending on lesion size and anatomy, a combination of plain radiogra-•
phy, CT, gadolinium-enhanced MRI, or radionuclide bone scan may be
necessary to adequately characterize tumor morphology. OOs are typically
characterized by an intracortical nidus with fusiform cortical thickening,
reactive sclerosis, and variable surrounding bone marrow edema.
OOs are one of the best indications for minimally invasive percutaneous •
thermoablation. Radiofrequency ablation for OOs is performed under gen-
eral anesthesia and computed tomography guidance with excellent clinical
results and minimal complications.
Radiofrequency ablation has been also successfully applied for the eradi-•
cation of osteoblastomas, chondroblastomas, giant cell tumors, enchon-
dromas, eosinophilic granulomas, bone hemangiomas, and intracortical
chondromas. Cytoreduction of sacral chordomas and sarcomas, and local
control of aggressive desmoid tumors with percutaneous ablative methods
have been also reported.
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14 Ablation of Primary Bone and Soft Tissue Tumors
Petsas T, Megas P, Papathanassiou Z. Radiofrequency ablation of two femoral head chondroblas-
tomas. Eur J Radiol. 2007;63(1):63–7. Epub 2007 May 4.
Sabharwal T, Katsanos K, Buy X, Gangi A. Image-guided ablation therapy of bone tumors. Semin
Ultrasound CT MR. 2009;30(2):78–90.
Welch BT, Welch TJ. Percutaneous ablation of benign bone tumors. Tech Vasc Interv Radiol.
2011;14(3):118–23.
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183
T. Clark, T. Sabharwal (eds.), Interventional Radiology Techniques in Ablation,
Techniques in Interventional Radiology,
DOI 10.1007/978-0-85729-094-6, © Springer-Verlag London 2013
A
Adrenal ablation, primary tumors and
metastatic disease
clinical features , 147–148
complications , 157
diagnostic evaluation
biochemical work-up , 148
clinical , 148
cross-sectional imaging , 149
indications/contraindications
alternative therapy , 157
anatomy , 150
equipment , 150–152
follow-up and postprocedure
medications , 156
patient preparation , 149
performing procedure , 154–155
planning , 154
postprocedure care , 155
preprocedure medications , 153–154
results , 156–157
treatment , 156
Ahmed, I. , 1
AngioDynamics’ StarBurst
®
radiofrequency
ablation system , 9–10
Autonomously functioning thyroid nodules
(AFTNs) , 53, 66
B
Baek, J.H. , 2
Baere, T. , 129
Beland, M.D. , 2
Biopsy, renal ablation , 141–142
Bismuth-Couinaud system , 118
Bitton, R.R. , 2
Boston Scienti fi c RS 3000 RF ablation
generator , 7–8
Breast ablation
considerations , 91
cryoablation
for breast cancer , 80
for fi broadenomas , 81
for preoperative lesion marking , 82
procedure , 82
focused ultrasound (FUS)
for breast cancer , 90
for fi broadenomas , 90
MR guidance , 87
patient preparation , 87–88
planning and treatment , 88–90
for preoperative lesion marking ,
90–91
procedure , 87
laser ablation (LA)
of breast cancer , 86
for fi broadenomas , 86
Nd:YAG lasers , 85
procedure , 86
microwave ablation (MWA)
in breast cancer , 84–85
procedure , 84
probe-based ablations , 75
radio frequency ablation (RFA)
in breast cancer , 83
in fi broadenoma , 83
procedure , 82
standard management of breast cancer ,
73–79
Brown, B. , 2
Index
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184
Index
C
Cellular necrosis , 38
Chemical ablation
cellular effects , 38
chemical agents , 38
clinical applications
neurolysis , 39
tumor ablation , 38–39
limitations , 40
vascular effects , 38
Chen, M.S. , 124
Chest wall disease. See Thoracic ablation
Chondroblastomas, soft tissue tumors , 179
Coblation technology , 44, 46
Colorectal metastases , 125–126
Computed tomography (CT) , 47
Covidien Cool-Tip RF ablation system , 8–9
Cranio-caudal (longitudinal) approach method , 61
Cryoablation
adrenal ablation , 150, 152, 155, 156
advantages , 16–17
breast ablation
for breast cancer , 80
clinical trials , 76
for fi broadenomas , 81
for preoperative lesion marking , 82
procedure , 82
components , 15–16
cost , 16
cryoprobe design , 15
de fi nition , 13
development , 18
disadvantages , 17–18
hepatocellular carcinoma , 119, 125
mechanism of action , 13–15
percutaneous prostate
anesthesia , 163
complications , 167
equipment , 163
follow-up , 165–166
freezing cycle , 165
gynecological position , 164
image guidance modality , 162–163
immediate postprocedure care , 165
mechanisms , 162
probe positioning , 164, 165
procedure , 164–165
retrospective analysis , 166–167
Cryoshock , 17
D
Daniel, B.L. , 2
Diagnostic ultrasonography , 30
Dielectric hysteresis technique See Microwave
ablation (MWA)
Diode lasers , 35
E
Erinjeri, J.P. , 1
Ethanol ablation (EA), thyroid and parathyroid
nodules , 66–67
Extracorporeal devices, transducers , 33
F
Fluoroscopy , 47–48
Focal therapy, prostate cancer
contraindications , 170
indications , 169
Focused ultrasound (FUS). See High-intensity
focused ultrasound (HIFU) ablation
Fotiadis, N. , 2
G
Gangi, A. , 2
Garnon, J. , 1
Ground glass opacity (GGO) , 106
H
Hepatic ablation
hepatocellular carcinoma
anatomy , 118–119
clinical features , 115
contraindications , 117
cryoablation , 119, 125
diagnostic evaluation , 116
equipment , 119
follow-up and postprocedure
medications , 123
immediate postprocedure care , 123
indications , 116–117
microwave ablation , 122, 125
patient preparation , 117
percutaneous ethanol ablation ,
120–121
preprocedure imaging , 121
preprocedure medications , 120
radiofrequency ablation , 121–122,
124–125
metastatic disease
colorectal , 125–126
complications , 127–129
inoperable hepatic , 126
transplantation , 126–127
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185
Index
HIFU. See High-intensity focused ultrasound
(HIFU) ablation
High-intensity focused ultrasound (HIFU)
ablation
breast ablation
for breast cancer , 90
clinical trials , 78, 79
for fi broadenomas , 90
MR guidance , 87
patient preparation , 87–88
planning and treatment , 88–90
for preoperative lesion marking , 90–91
procedure , 87
clinical applications
focused US surgery , 34–35
immune response enhancement , 35
targeted drug delivery , 35
vessel occlusion , 35
equipment
image guidance , 33–34
phased array technology , 32
transducers , 32–33
history , 29–30
mechanical effect , 31–32
principles , 30
prostrate ablation , 167–168
thermal effect , 30–31
thyroid and parathyroid nodules , 67
Huang, J. , 124
Huber, P.E. , 90
Hydrossicetion , 142
Hyperparathyroidism , 53
I
Immune response enhancement , 35
Interstitial transducer , 33
J
Jeffrey, S.S. , 83
K
Klein, J.A. , 1
Konstantinos, k. , 2
Krokidis, M. , 1
L
Lang, H. , 2
Laser ablation (LA)
breast ablation
of breast cancer , 86
clinical trials , 77
for fi broadenomas , 86
Nd:YAG lasers , 85
procedure , 86
interstitial ablation
clinical indications , 36
laser system, characteristics of ,
35–36
mechanisms of action , 36
procedure , 36–37
prostate ablation , 169
Laser-induced interstitial thermo-therapy
(LIIT). See Laser ablation (LA)
Lateral approach method , 61
Lee, H. , 107
LeVeen electrode , 7
LeVeen, R.F. , 7
Liver ablation. See Hepatic ablation
Livraghi, T. , 128, 129
Long, J.P. , 166
Lung tumor ablation. See Thoracic ablation
M
Mayo-Smith, W. , 2
Metastatic disease, hepatic ablation
alternative therapies , 126–127
colorectal , 125–126
complications , 127–129
inoperable hepatic , 126
Microwave ablation (MWA)
breast ablation
in breast cancer , 84–85
clinical trials , 77
procedure , 84
equipment
advantages , 24–27
components , 22–24
cost , 22
disadvantages , 27
future aspects , 28
hepatocellular carcinoma ,
119, 122, 125
tissue heating , 21
Minimally invasive ablation therapy, prostate
ablation , 161
Moving shot technique , 60–62
MWA. See Microwave ablation
(MWA)
N
Nd:YAG laser , 35
Neurolysis , 39
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186
Index
O
Osteoblastomas, soft tissue tumors , 178–179
Osteoid osteoma (OO), primary bone ablation
alternative therapies , 174
complications , 178
contraindications , 176
CT features , 174
CT imaging , 176
differential diagnosis , 175
imaging features , 174–175
patient preparation and anesthesia , 176
percutaneous RF ablation , 175
radiofrequency ablation , 177
thermal monitoring and organ insulation ,
177
thermoablation , 176–177
treatment , 178
P
Palliative setting, thoracic ablation , 99
Percutaneous ablation therapy
contraindications , 162
indications , 161
intervention , 162
Percutaneous cryoablation , 13
Percutaneous discectomy/nucleoplasty , 46, 48
Percutaneous ethanol ablation, hepatocellular
carcinoma , 120–121
Percutaneous ethanol injection (PEI),
hepatocellular carcinoma , 119, 124
Percutaneous laser ablation (PLA), thyroid and
parathyroid nodules , 67
Petsas, T. , 2
Phased array technology , 32
Pheochromocytoma, adrenal ablation ,
147–149, 153
Photodynamic therapy
complications , 169
de fi nition , 168
ef fi cacy of , 168
Plasma cavitation , 46
Plasma, de fi nition , 44
Plasma-mediated ablation
complications , 48–49
de fi nitions , 43
image guidance and lesion access , 46–47
indications for use , 46
mechanism of action
coblation technology , 44, 46
electrosurgical techniques , 43
nonplasma settings , 45
plasma, de fi nition , 44
plasma settings , 45
treatment application , 47–48
treatment outcomes , 48
Pneumonectomy , 99
Pneumothorax , 109
Primary bone ablation
osteoid osteoma
ablation technique , 176–177
alternative therapies , 174
complications , 178
contraindications , 176
CT features , 174
CT imaging , 176
differential diagnosis , 175
imaging features , 174–175
patient preparation and anesthesia , 176
percutaneous RF ablation , 175
thermal monitoring and organ
insulation , 177
treatment , 178
soft tissue tumors
chondroblastomas , 179
osteoblastomas , 178–179
radiofrequency ablation , 179–180
Probe-based ablations , 75
Prostate ablation
clinical features
diagnosis , 160
staging , 160
curative , 161
de fi nition , 159
focal therapy , 169–170
HIFU
complications, urinary retention ,
167–168
results , 168
laser ablation , 169
percutaneous ablation therapy
contraindications , 162
indications , 161
laboratory studies , 162
percutaneous prostate cryoablation
anesthesia , 163
complications , 167
endpoint , 165
equipment , 163
follow-up , 165–166
freezing cycle , 165
gynecological position , 164
image guidance modality , 162–163
immediate postprocedure care , 165
mechanisms , 162
probe positioning , 164, 165
procedure , 164–165
retrospective analysis , 166–167
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