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(BQ) Part 1 book “Brant and helms’ fundamentals of diagnostic radiology” has contents: Diagnostic imaging methods, introduction to brain imaging, craniofacial trauma, cerebrovascular disease, central nervous system infections, spine imaging, pulmonary vascular disease,… and other contents.
SECTION EDITORS SECTION I BASIC PRINCIPLES William E Brant, MD, FACR Professor Emeritus Department of Radiology and Medical Imaging University of Virginia School of Medicine Charlottesville, Virginia SECTION II NEURORADIOLOGY Erik H L Gaensler, MD Clinical Professor Department of Radiology and Biomedical Imaging University of California, San Francisco Neuroradiologist Bay Imaging Consultants Jerome A Barakos, MD Director of Neuroimaging Department of Radiology California Pacific Medical Center San Francisco, California SECTION III CHEST Jeffrey S Klein, MD, FACR A Bradley Soule and John P Tampas Green and Gold Professor of Radiology Department of Radiology Larner College of Medicine at the University of Vermont Burlington, Vermont SECTION IV BREAST RADIOLOGY Brandi T Nicholson, MD, FSBI Associate Professor Department of Radiology and Medical Imaging University of Virginia School of Medicine Charlottesville, Virginia SECTION V CARDIAC RADIOLOGY Seth Kligerman, MD Associate Professor Division Chief of Cardiothoracic Radiology Department of Radiology University of California, San Diego San Diego, California SECTION VI VASCULAR AND INTERVENTIONAL RADIOLOGY Juan C Camacho, MD Assistant Attending Radiologist Interventional Radiology Memorial Sloan Kettering Cancer Center Assistant Professor Department of Radiology Weill Cornell Medical College New York, New York Akhilesh K Sista, MD, FSIR Associate Professor and Section Chief Vascular Interventional Radiology Department of Radiology New York University School of Medicine New York, New York SECTION VII GASTROINTESTINAL TRACT William E Brant, MD, FACR Professor Emeritus Department of Radiology and Medical Imaging University of Virginia School of Medicine Charlottesville, Virginia SECTION VIII GENITOURINARY TRACT William E Brant, MD, FACR Professor Emeritus Department of Radiology and Medical Imaging University of Virginia School of Medicine Charlottesville, Virginia involved percutaneous ethanol injection, termed ethanol ablation, which has been shown to safely achieve complete necrosis of small HCCs and has the advantage of allowing treatment of tumors near sensitive organs and blood vessels However, it typically requires multiple treatment sessions, one cannot be certain of the ablation zone, and there are high local progression and recurrence rates (Fig 39.23) FIGURE 39.22 Radiation lobectomy A: Celiac angiogram demonstrating a large mass within segment VII and VIII of the liver with corresponding tumor blush (arrows) B: SPECT-CT 90Y bremsstrahlung axial image confirming complete tumoral distribution by the therapy as well as counts within the normal liver C: Preprocedural contrast-enhanced CT at the level of the portal vein demonstrating a small left lateral segment which will become the future liver remnant D: Axial T1W postcontrast image demonstrating delayed enhancement of the right lobe corresponding to postprocedural fibrosis along with significant hypertrophy of the left lateral segment E: Intraoperative view of the liver corroborating significant hypertrophy of the left lateral segment and fibrosis of the treated right lobe (arrow) Acetic Acid Ablation Percutaneous acetic acid injection for ablation of tumors was first described in 1994 Acetic acid is a noxious chemical with better tissue diffusion than ethanol as well as better infiltration into tumor septae and capsules, proposed to decrease the number of repeat ablation sessions It is generally considered safe, with rare side effects including transient hemoglobinuria, fever, and right upper quadrant abdominal pain Segmental infarction and metabolic acidosis can occur at high doses TABLE 39.3 COMPARISON OF AVAILABLE SIRT PARTICLES TABLE 39.4 ADVANTAGES AND DISADVANTAGES OF EACH ABLATION METHOD Energy-Based Ablation Radiofrequency Ablation Radiofrequency ablation (RFA) utilizes a probe generating electromagnetic radiation within the radiofrequency spectrum, part of the electromagnetic spectrum bound by a low oscillation of Hz and a high of 300 GHz, with most RFA probes generating electromagnetic radiation in the 300 to 500 kHz range The probe is inserted within the target lesion, typically using CT or ultrasound guidance, and the circuit is closed by placing grounding pads on the patient’s body, usually the thighs A generator modulates the radiofrequency amplitude, and the resultant energy is locally deposited in the form of heat as a result of molecular frictional loss, resulting in coagulative tissue necrosis Effective ablation requires good tissue conductivity, which allows heat transfer farther away from the probe and a larger ablation zone Counterintuitively, a fast power increase will result in desiccation of the tissue around the probe, limiting heat conduction and decreasing the size of the ablation zone The eventual ablation zone geometry depends on multiple factors including the type and shape of the probe, maximum temperature reached, duration of ablation, and proximity to blood vessels Lesion size is the most important determinant of RFA success, with reported complete ablation rates of about 90% for lesions up to cm For lesions >3 cm, the efficacy of RFA decreases with increasing lesion size Complete ablation is possible for lesions of to cm but unlikely with lesions >5 cm The rate of recurrence is nearly 0% for smaller lesions and >50% for lesions >5 cm Lesion location is also a determinant of RFA success RFA of lesions near the hilum is generally avoided due to the risk of injury to the central biliary tree or hepatic vasculature Additionally, lesions adjacent to blood vessels may show variable ablation response secondary to the heatsink effect, whereby generated heat is dissipated by the adjacent flowing flood FIGURE 39.23 Percutaneous ethanol ablation A: Axial T1W postcontrast image in the hepatobiliary phase demonstrating a lesion within the posterior aspect of segment III (arrow), in close proximity to the stomach, the portal vein and adjacent bile ducts, in a patient that underwent right hepatectomy due to metastatic colorectal cancer B: CT image demonstrating needle placement within the lesion C: Subsequent ethanol injection was performed, which was confirmed by noncontract CT (arrow) D: Axial T1W postprocedural image demonstrating absence of enhancement of the ablation cavity, compatible with lesion necrosis (arrow) RFA may offer the same benefit as resection in selected patients Child– Pugh class A or B patients with lesions up to cm treated with RFA demonstrate similar overall survival rates to those treated with surgical resection Although Child–Pugh class C patients may be safely treated with RFA, their life expectancy is determined by the progression of cirrhosis and a survival benefit is therefore unlikely Liver transplantation for HCC offers the longest survival for the approximately 10% of patients who are candidates, and treatment with RFA while awaiting liver transplantation has been shown to be an independent prognostic factor for longer survival Deaths after RFA are uncommon and typically attributed to liver failure, and risk increases with larger ablation volumes and diminished hepatic reserve Most patients treated with RFA for HCC may be discharged home on the day of the procedure after several hours of observation Microwave Ablation Microwave ablation (MWA) refers to all electromagnetic methods of inducing tumor destruction via coagulative tissue necrosis by using devices with frequencies greater than or equal to 900 MHz MWA uses an oscillating electromagnetic field that realigns polarized molecules such as water, generating kinetic energy, heat, and subsequent tumor necrosis through dielectric hysteresis This creates an ablation zone around the needle in a column or rounded shape, depending on the type of needle used and the generating power Compared to RFA, MWA shows more uniform tissue penetration, does not require grounding pads, is less prone to heat-sink effect, is not affected by tissue carbonization, and has a more predictable ablation zone (Fig 39.24) Cryoablation Most cryoablation systems rely on the Joule–Thomson effect, whereby expansion of a cryogen (i.e., argon) at the cryoprobe tip causes the temperature to decrease Cell death induced by cryoablation is caused by direct intracellular ice crystal formation resulting in damage to plasma membranes and organelles The ice crystals continue to grow during thawing, maximizing cell killing Tumor response depends on the rate of cooling, depth of hypothermia, rate of thawing, the number of freeze–thaw cycles, and delayed effects of postthaw ischemia Repeated freeze–thaw cycles can improve the efficacy The large diameter of currently available probes, the requirement of using multiple probes, the location of many tumors, and the risk of cryoshock syndrome, a clinical syndrome caused by circulating inflammatory cytokines and characterized by renal failure, disseminated intravascular coagulation, and adult respiratory distress syndrome, significantly limit its application in the liver Irreversible Electroporation Irreversible electroporation (IRE) uses pulsed electric fields to induce cell death At a specific electric potential threshold, the cell membrane lipid bilayer becomes inundated with pores, a change that is reversible at low current but which becomes permanent and results in cell death as the electric field strength is increased Ablation of liver lesions using IRE was first described in 2005 by Davalos et al IRE devices can deliver up to 3,000 V and 50 A through either unipolar or bipolar needle electrodes Ablation zone size can be influenced by length of the electrode tip, distance between electrodes, pulse number, duration of pulses, and voltage applied Electric fields are strongly influenced by the conductivity of the local environment, which depends on tissue heterogeneity and the presence of metal such as biliary stents Since IRE does not depend on heating or cooling of target tissues, the technique is not limited by the heat-sink effect when performing ablation of tumors close to major blood vessels and does not appear to have deleterious effects on adjacent normal tissues including nerves and bile ducts However, despite these advantages over thermal ablative techniques, multiple groups have suggested poor local control and high recurrence rates with IRE Therefore, IRE should only be considered when thermal ablative techniques are contraindicated FIGURE 39.24 Percutaneous microwave ablation A: Contrast-enhanced CT image demonstrating a lesion within the posterior right lobe (arrow) B: Noncontrast CT image demonstrating the exophytic lesion during the actual procedure (arrow) C: Subsequently, a microwave antennae was advanced into the lesion under direct ultrasound guidance D: Immediate postprocedural ultrasound demonstrating expected postprocedural changes (arrow) with (E) the expected perilesional halo on noncontrast CT (arrow), indicating technical success and tissue retraction FIGURE 39.25 Scheme demonstrating the available follow-up criteria and their specific therapeutic targets Laser Ablation Laser ablation uses a laser to generate monochromatic light and a small flexible optical fiber to transport the light inside tissue where it is then converted to heat Tumor cell exposure to temperatures ranging from 45° to 55°C for prolonged periods or temperatures higher than 60°C for short periods causes irreversible cell damage Heat generation in the target tissue is influenced by multiple factors including laser light wavelength, laser power, laser energy, treatment time, the emission characteristics of the optical fiber, and characteristics of the tissue Various invasive and noninvasive methods are available for real-time temperature monitoring with good spatial resolution, facilitating tumor killing with sparing of as much normal tissue as possible Additionally, nanoparticles are being developed for use in photothermal tumor ablation that highly absorb light and can be designed and delivered specifically to tumor cells FIGURE 39.26 Scheme demonstrating the available anatomic criteria and their basic measuring strategies PRINCIPLES OF ASSESSING TREATMENT RESPONSE Assessment of tumor response is crucial in patients undergoing locoregional liver cancer therapies Conventional methods, such as classical Response Evaluation Criteria in Solid Tumors (RECIST) criteria, have no predictive value in HCC patients treated with TACE or SIRT as they rely solely on tumor shrinkage as a measure of antitumor activity, an assumption that is only valid with cytotoxic drugs TACE and SIRT induce direct tumor necrosis and their anticancer activity is predictive to a reduction in viable tumor, as identified by contrast-enhanced CT or MRI The Clinical Practice Guidelines jointly issued by the European Association for the Study of Liver Disease (EASL) and the European Organization for Research and Treatment of Cancer (EORTC) therefore state that assessment of response in HCC should be based on modified RECIST (mRECIST) criteria by performing contrast-enhanced CT or MRI weeks after treatment to assess residual viable tumor burden as well as for vascular invasion, lymph nodes, ascites, pleural effusion, and new lesions Tumor response measured by mRECIST after TACE has been shown to correlate with survival outcomes (Figs 39.25 and 39.26) If complete tumor necrosis is not achieved after the first TACE, a second TACE may be performed as some feeding arteries may have been missed However, patients that not respond to two consecutive sessions of TACE should be considered for alternative therapies, and those that show no tumor response following TACE have a worse prognosis All response criteria that measure the tumor dimensionally (RECIST and mRECIST), presume that lesion diameter directly correlates with lesion volume This assumption is based on the belief that tumors grow and shrink in a spherical manner, which is not entirely accurate Therefore, quantification by volumetry can be a more accurate reflection of the actual tumor size and additional methods have been developed in order to quantify such a change Also, quantitative imaging techniques allow robust evaluation of hepatic tumor response In addition to size changes, various biologic and functional parameters such as diffusion and perfusion can be quantified Measurement of these parameters is especially important for the evaluation of tumor response to novel targeted therapies including SIRT, in which a change in functional status sometimes precedes anatomic modification Other biomarkers have been explored including AFP Preprocedural AFP has not been demonstrated to be a prognostic marker of clinical response following intervention AFP elevation may be seen in the immediate postprocedure period secondary to cellular lysis rather than disease progression, and while decrease in AFP following treatment is indicative of response, it is unreliable and AFP monitoring should not be substituted in place of dynamic imaging studies CONCLUSION Management of hepatic malignancies requires a multidisciplinary approach and the ability to translate basic anatomical and radiologic concepts into daily clinical practice Decisions are often based on the tumor burden, liver function, imaging findings, and patient presentation, including a judicious evaluation of patient performance status Locoregional therapies offer multiple options with different treatment objectives Currently, ablation therapies including SIRT segmentectomy can be used in a potentially curative manner The remaining therapies are typically used in a palliative or downstaging setting Each of the available locoregional treatments offers specific advantages and must be individualized to each patient in order to achieve the desired optimal outcome Suggested Readings Arch-Ferrer JE, Smith JK, Bynon S, et al Radio-frequency ablation in cirrhotic patients with 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BRANT AND HELMS’ FUNDAMENTALS OF DIAGNOSTIC RADIOLOGY FIFTH EDITION ■ EDITORS JEFFREY S KLEIN, MD, FACR A Bradley Soule and John P Tampas Green and Gold Professor of Radiology Department of Radiology. .. Kligerman (Chapter 24 figures 7, 8, 12 15 , 17 and 27; Chapter 25 all figures; Chapter 26 figures 4–7, 9, 10 , 16 ; Chapter 27 figures 7–9, 12 , 13 , 15 , 17 18 , 21 24, 27, 29 and 30; Chapter 28 all figures;... E Brant, MD, FACR Professor Emeritus Department of Radiology and Medical Imaging University of Virginia School of Medicine Charlottesville, Virginia Alan S Brody, MD Professor of Radiology and