Percutaneous Navigation under Local Anesthesia for Computed Tomography-Guided Microwave Ablation of Malignant Liver Lesions Located in the Hepatic Dome

Background and Objectives: The aim of the present study was to report the safety and efficacy of percutaneous navigation under local anesthesia for computed tomography-guided microwave ablation of malignant liver lesions located in the hepatic dome. Patients with primary and secondary malignant liver lesions located in the hepatic dome who underwent percutaneous computed tomography-guided microwave ablation using a computer-assisted navigation system under local anesthesia were prospectively evaluated. The primary objective was technical success. Materials and Methods: The sample consisted of 10 participants (16 lesions) with a mean age of 60.60 years (SD = 9.25 years) and a mean size of 20.37 ± 7.29 cm, and the mean follow-up time was 3.4 months (SD = 1.41) months. Results: Primary technical success was 93.75%. Tumor remnant was noticed at one month follow-up in a single metastatic lesion, which was re-treated with an ablation session, and no tumor remnant was depicted in the subsequent imaging follow-up (secondary technical success 100%). Grade I self-limited complications (according to the CIRSE classification system) included small pleural effusion (n = 1) and minor bleeding post antenna removal (n = 1) requiring nothing but observation. Conclusions: the findings of the present study indicate that percutaneous navigation under local anesthesia is a safe and efficacious approach for computed tomography-guided microwave ablation of malignant liver lesions located in the hepatic dome. Large randomized controlled studies are warranted to observe treatment effectiveness and compare the results with those of other options.

Tumor Remnant After Silicone Implant en Block Capsulectomy: The Magnetic Resonance Role

Recently, there has been an increase in surgeries to treat silicone implants complications. These procedures are generally related to diseased fibrous capsules, whose most common clinical manifestation is capsular contracture. Other frequently found presentations are intracapsular collection and local inflammatory signs. The causes of these complications are not well established. Some reports associate them with the implant texture, gel bleeding, silicone-induced granuloma, and infectious processes. Although rare, there is an association with malignant neoplasia in the literature, where Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is the most severe complication. Patients often do not perform a Magnetic Resonance (MRI) scan for the explant surgical programming.The accuracy of MRI to assess fibrous capsule tumor remnants depends on the surgical time. The ideal time for the evaluation is up to 72 hours after the surgical time when the repair tissue starts to appear. Up to 2-3 weeks after surgery, MRI can provide information regarding the presence of a residual tumor. After this period, the presence of scar tissue impairs the analysis. This short report discusses the role of MRI in the evaluation of residual fibrous capsules in the postoperative period.

The surgical challenge of ossified ventrolateral spinal meningiomas: tricks and pearls for managing large ossified meningiomas of the thoracic spine

The authors present an illustrative technical note on microsurgical resection of ventrolateral completely ossified spinal meningiomas (OSMs) and a literature review of the surgical management of calcified spinal meningiomas or OSMs. These tumors are surgically demanding due to their solid consistency, especially when in a ventrolateral location with dislocation of the spinal cord. A challenging case with significant thoracic cord compression and displacement is described. Due to the firm consistency and the ventrolateral localization of the meningioma, a piecemeal resection was necessary. This could have resulted in a free-floating tumor remnant adherent to the spinal cord, impeding safe tumor resection. To avoid such a remnant, an anchoring burr hole was drilled at the border between the spinal cord and the adamantine tumor mass. Then, a microdissector was placed within the anchoring burr hole and the tumor was gently pulled laterally while drilling away the medial parts of the ossified tumor. This procedure was repeated until separation of the tumor from the spinal cord was possible and a gross-total resection (Simpson grade II) was manageable. Throughout the procedure, continuous intraoperative neurophysiological monitoring was performed.

Management of a primary cardiac leiomyosarcoma in a young woman

Cardiac leiomyosarcoma is an extremely rare tumor with a poor prognosis. An 18-year-old female patient was admitted to our clinic with a left atrial leiomyosarcoma extending to the right lower pulmonary veins. We performed complete tumor excision by the right anterolateral mini-thoracotomy approach using minimally invasive techniques. After pathological confirmation of the tumor, right lower lobectomy was performed with the same incision one week later to prevent recurrence. Although no tumor remnant was found in the lobectomy specimen, adjuvant chemotherapy was started. No recurrence was detected during the 12-month follow-up. In conclusion, the right submammarian minithoracotomy approach has the advantages of its less invasive nature and suitability for complete tumor resection with lobectomy.

Precise enhancement quantification in post-operative MRI as an indicator of residual tumor impact is associated with survival in patients with glioblastoma

Glioblastoma is the most common primary brain tumor. Standard therapy consists of maximum safe resection combined with adjuvant radiochemotherapy followed by chemotherapy with temozolomide, however prognosis is extremely poor. Assessment of the residual tumor after surgery and patient stratification into prognostic groups (i.e., by tumor volume) is currently hindered by the subjective evaluation of residual enhancement in medical images (magnetic resonance imaging [MRI]). Furthermore, objective evidence defining the optimal time to acquire the images is lacking. We analyzed 144 patients with glioblastoma, objectively quantified the enhancing residual tumor through computational image analysis and assessed the correlation with survival. Pathological enhancement thickness on post-surgical MRI correlated with survival (hazard ratio: 1.98, p < 0.001). The prognostic value of several imaging and clinical variables was analyzed individually and combined (radiomics AUC 0.71, p = 0.07; combined AUC 0.72, p < 0.001). Residual enhancement thickness and radiomics complemented clinical data for prognosis stratification in patients with glioblastoma. Significant results were only obtained for scans performed between 24 and 72 h after surgery, raising the possibility of confounding non-tumor enhancement in very early post-surgery MRI. Regarding the extent of resection, and in agreement with recent studies, the association between the measured tumor remnant and survival supports maximal safe resection whenever possible.

MON-326 Non Functioning Pituitary Adenomas (NFPA): Sex Related Differences in Presentation, Clinical Features and Outcomes

INTRODUCTION: NFPA are characterized as tumors without a typical hormonal hypersecretion syndrome. They are frequently diagnosed in the sixth decade, by visual field defects, hypopituitarism or incidentally. PATIENTS AND METHODS: retrospective and observational study that included 103 patients with NFPA (60 females) who were seen between 1999 and 2019 in our hospital. We compared and analyzed patients characteristics by sex: reason for consultation, hormonal status at diagnosis, invasiveness of the tumor through MRI, treatments and outcomeRESULTS: out of 103 patients, 58,2% were women (W). Men (M) were significantly older than women (56 vs. 45 yold. p=0,002). The presence of a macroadenoma was similar in both sexes (93%W vs. 94,7% M), however tumor invasiveness was more frequent in men (50% vs. 24,6%). Most men consulted for incidental finding (47,4% vs. 29,8%); most women consulted for symptoms related to the tumor(70% vs 52%): hypogonadism 31,6% W, 13% M; galactorrhea 17% W; visual field defects 21,7% W, 23,7%M, pituitary apoplexy 11,6% M. At baseline hormonal assessment hyperprolactinemia was more frequent (50,9% vs 42%) and higher in women (mean PRL levels 75 ng/ml vs. 37 ng/ml). Hypogonadism was more frequent in men (54% vs 42%) as well as hypopituitarism (15% vs. 10,5%). Surgery was the most used therapy in both sexes (69% M vs. 73%W) but males required more frequently second surgery and radiotherapy than females (15% vs. 5% and 10% vs. 5% respectively). Gonadotropin secreting adenoma was diagnosed in 62% of men and 37,5% by tumor immunohistochemistry, in the 45% of women who presented negative immunostaining the presence of a gonadotrophic lineage is not ruled out, median Ki-67 labeling was low in both sexes (2%). After surgery 66% of men and 37% of women showed tumor remnant &gt; 1cm (p=0,001), tumor regrowth was seen in 38,4% men and 10,4% women (p=0,03). Hypogonadism was greater in men than in women (56% vs 39%). Ninety two percent of men and 60,9% of women developed some degree of pituitary deficiency after surgery (P&lt;0,001). Men showed a higher degree of complete hypopituitarism compared to women (pretreatment 15% vs 10,5%, post treatment 32% vs 13%). CONCLUSION: NFPA in men are usually diagnosed incidentally at an older age, are more invasive at presentation with a higher incidence of pituitary dysfunction. Moreover, they presented with greater rate of tumor regrowth and hypopituitarism after surgery. NFPA in women are diagnosed earlier due to endocrine symptoms, had lower degree of invasiveness with better outcomes after treatment. Sex related differences in NFPA may be associated with the delay in diagnosis, although a more aggressive biology cannot be discarded.

Usefulness of cold polypectomy under linked color imaging

Background and study aims Cold polypectomy is becoming popular for treatment of colon polyps due to its safety and convenience, but there is still the problem of tumor remnants. Because linked color imaging (LCI) improves polyp visibility, cold polypectomy under LCI is anticipated to reduce the tumor remnant rate. Therefore, we investigated the usefulness of this procedure. Patients and methods Fifty patients scheduled to undergo cold polypectomy for treatment of colon polyps < 10 mm and assumed to be adenomas were registered prospectively. After performing cold snare polypectomy (CSP) under LCI, biopsy was performed at two resection margin sites for each polyp to determine the tumor remnant rate. Results A total of 145 lesions were treated by CSP. Of the 139 lesions in which polyps were retrievable and diagnosed as adenomas pathologically, one lesion was recognized as a remnant adenoma on biopsy (remnant rate: 0.7 % [95 % CI: 0.0–4.4]). This remnant rate was extremely low. Treatment results were extremely promising given that en bloc resection, post-procedure bleeding, and perforation rates were 100 %, 0 %, and 0 %, respectively. Conclusion Cold snare polypectomy under LCI may be an effective treatment method capable of reducing the tumor remnant rate. This trial was approved by our Institutional Ethics Committee and registered at the University Hospital Medical Information Network (UMIN 000033690).

Single-incision laparoscopic ileocecal resection in a 10-year-old child with appendiceal neuroendocrine tumor

Background In Japan, the majority of gastrointestinal tract neuroendocrine tumors (NETs) have been reported to originate from the rectum, and appendiceal NETs are relatively rare. Preoperative diagnosis is very difficult and it is diagnosed after appendectomy. Pediatric appendiceal NET is a disease with a good prognosis. However, in rare cases, lymph node metastasis could occur and additional resection is required. Case presentation A 10-year-old boy complained of right lower quadrant abdominal pain and underwent an appendectomy under a diagnosis of acute appendicitis in previous hospital. The final diagnosis was appendiceal NET, so he was referred to our department for additional resection. The tumor was found in the base of the appendix and invasively reached the subserosal layer with obvious vascular invasion. His Ki-67 index was 1 to 2%, so we classified it as appendiceal NET G1 according to the WHO 2015 classification. We considered the possibility of a tumor remnant or lymph node metastasis, so we performed single-incision laparoscopy with D3 lymph node dissection. The pathological diagnosis revealed no tumor remnant but metastasis to one lymph node. He was discharged on the 9th postoperative day. There has been no recurrence at 3 years and 7 months after surgery. Conclusion When the tumor size is 10–20 mm, the frequency of lymph node metastasis in some reports is variable, and there is no consensus yet on the indications for additional resection. However, there are definitely a certain number of cases with lymph node metastasis that require additional resection. In the present patient, long-term survival can be obtained by additional resection. At present, factors such as the presence of vascular or lymph node invasion and the malignancy grade and tumor’s location must be considered on a case-by-case basis. Although the incidence rate of appendiceal NET is rare, the diagnosis can be made only during postoperative pathological examination; thus, reliable histopathological examination is required.

Use of radiotherapy after pituitary surgery for non-functioning pituitary adenomas

Surgery is the treatment of choice for non-functioning pituitary macroadenomas (NFPAs). In cases of postoperative remnant growth or tumor recurrence, radiotherapy (RT) can be considered. The role of RT in the postoperative management of NFPAs is still debated. The main arguments against routine use of RT are the lack of randomized controlled trials, the use of clinically irrelevant endpoints in most studies on RT, the benign character of the condition, the potential for side effects of RT, and the option to apply RT at a later stage. However, because of its excellent efficacy in inhibiting tumor growth, reducing tumor volume and improving any existing visual defects, and as its side effects seem to be limited compared to the benefits provided, RT keeps a place in the management of NFPAs when a tumor remnant persists, particularly if it is invasive and displays high proliferation markers, if surveillance shows a relevant increase in tumor volume or if the tumor is close to the optic chiasm. The size of the remnant, its vicinity with the optic pathways, and the potential risk to healthy surrounding tissues need to be considered when deciding on an RT procedure.

Review of first clinical experiences with a 1.5 Tesla ceiling-mounted moveable intraoperative MRI system in Europe

High-field intraoperative MRI (iMRI) systems provide excellent imaging quality and are used for resection control and update of image guidance systems in a number of centers. A ceiling-mounted intraoperative MRI system has several advantages compared to a conventional iMRI system. In this article, we report on first clinical experience with using such a state-of-the-art, the 1.5T iMRI system, in Europe. A total of 50 consecutive patients with intracranial tumors and vascular lesions were operated in the iMRI unit. We analyzed the patients’ data, surgery preparation times, intraoperative scans, surgical time, and radicality of tumor removal. Patients’ mean age was 46 years (range 8 to 77 years) and the median surgical procedure time was 5 hours (range 1 to 11 hours). The lesions included 6 low-grade gliomas, 8 grade III astrocytomas, 10 glioblastomas, 7 metastases, 7 pituitary adenomas, 2 cavernomas, 2 lymphomas, 1 cortical dysplasia, 3 aneurysms, 1 arterio-venous malformation and 1 extracranial-intracranial bypass, 1 clival chordoma, and 1 Chiari malformation. In the surgical treatment of tumor lesions, intraoperative imaging depicted tumor remnant in 29.7% of the cases, which led to a change in the intraoperative strategy. The mobile 1.5T iMRI system proved to be safe and allowed an optimal workflow in the iMRI unit. Due to the fact that the MRI scanner is moved into the operating room only for imaging, the working environment is comparable to a regular operating room.