Techniques in Vascular and Interventional Radiology最新文献

Thyroid nodules are common and often asymptomatic. However, patients may seek treatment for nonfunctional benign nodules that cause compressive symptoms or cosmetic problems. Additionally, many patients with autonomously functioning nodules also seek treatment. As minimally invasive thermal ablation techniques become more wide spread, providers offering these treatments should be familiar with the pathophysiology of thyroid nodules, and with how to work up a patient with nodular thyroid disease.

In the past decade, there has seen been a shift from treating all thyroid cancer surgically, to favoring less aggressive approaches for low-risk thyroid cancer. Surgery was historically the treatment of choice for most thyroid cancer. Active surveillance has emerged as an alternative for low-risk thyroid cancer in select patients. This approach has been accepted worldwide, and sound evidence supports its oncological safety in carefully selected patients. However, not all patients want to undergo lifelong monitoring, and some patients may wish to treat their cancer in a minimally invasive manner. Thermal ablation has developed as a minimally invasive alternative to surgery and active surveillance for well selected patients with thyroid malignancy. Herein, we review the role of thermally ablative techniques, specifically radiofrequency ablation, for the treatment of small primary thyroid cancers, recurrent thyroid cancer, and lymph node metastases.

A good understanding of the anatomic structures of the neck surrounding the thyroid gland is a requisite for safely performing image guided procedures on the thyroid gland. Patients presenting for treatment of thyroid nodules can have anatomy that is distorted by the nodules or by prior surgery. This pictorial review describes the anatomy of the thyroid gland and surrounding structures. Additionally, a review of how to perform an ultrasound exam of the thyroid gland and how to categorize thyroid nodules is included.

Radiofrequency ablation (RFA) is an increasingly popular non-surgical alternative for the treatment of benign thyroid nodules. Although RFA is less invasive than surgery, it is not without its own risks with major complications occurring at a rate ranging up to 3.8% in large systematic reviews. We review the range of minor and major complications that have been described after thyroid RFA and their potential management. We also review recommended post-ablation follow-up schedules as well as expectations on thyroid nodule volume rate reduction after treatment. Long term follow-up is necessary as there can be regrowth of ablated thyroid nodules due to an undertreated nodule margin. Overall, RFA has been shown to be a consistently safe and effective treatment for thyroid nodules with excellent long-term results.

Symptomatic solid benign thyroid nodules may present either as nonfunctioning nodules causing compressive symptoms or as hyperfunctioning nodules causing symptoms of hyperthyroidism. While surgical resection or radioiodine ablation of these nodules can be performed, percutaneous radiofrequency ablation (RFA) of benign solid thyroid nodules has been shown to be a safe and effective alternative in select patients. Preprocedural evaluation should include a history focusing on signs and symptoms of thyroid dysfunction, a physical exam, thyroid ultrasound, thyroid function tests, and discussion of key intraprocedural details with the patient such as the anesthesia plan and risks. Thyroid RFA can be safely performed as an outpatient procedure with less than 2% major and minor complication rates. This report will focus on the basic technique of performing RFA for symptomatic thyroid nodules.

The optimal treatment option for cystic thyroid lesions depends on the composition of the lesion, prior interventions, and patient preference. Simple aspiration is a good initial diagnostic and treatment modality for thyroid lesions that are predominantly cystic. However, recurrence rates are high and, should fluid re-accumulate, further aspirations are unlikely to be effective. Ethanol ablation is an excellent first line treatment as it is relatively safe, well-tolerated, and simple to perform. It is at least as effective, if not more effective, than radiofrequency ablation (RFA) for simple cysts, and complex thyroid cysts with a solid component <20%. The efficacy of EA is inversely related to the percentage of solid component within any given lesion. There is some evidence that complex cysts with >20% solid component may have better long-term outcomes with RFA over EA, although EA is still a reasonable first line consideration. RFA salvage after EA is possible and effective, especially for complex nodules with larger solid components.

Oncology patients, particularly those with breast, colorectal, prostate, renal and pancreatic cancers, are living longer due to advances in detection, and treatment. Unfortunately, this has come with a commensurate increase in the prevalence of osseous metastases and skeletal related events approaching 100,000 new patients each year. Patients are now experiencing serious morbidity and mortality due to pathologic fractures, altered structural mechanics, and cancer related bone pain. This patient population poses challenges for conventional open surgical and/or medical management often due to disease extent, location, and, in general, poor surgical candidacy. Percutaneous techniques may also be challenging under image guidance due to limited ability to use traditional orthopedic corridors, loss of cortical landmarks with destructive lesions, and need for live image guidance. Modern angiography suites with cone beam computed tomography (CBCT) and advanced imaging applications including needle guidance, 3D fusion, tumor segmentation, and angio-CT have facilitated the development of novel minimally invasive techniques for pain palliation and stabilization. The interventional radiologist is uniquely positioned to harness these advanced imaging applications and offer effective, safe, minimally invasive treatment options to patients with neoplastic disease within the axial, and appendicular skeletons. The focus of this article is to address the technical aspects of patient preparation, positioning, advanced imaging system capabilities, guidance strategies, and pitfalls during osteoplasty and fixation procedures.

Bone stabilization procedures performed by Interventional Radiologists have significantly increased in the past ten years with a wide variety of techniques available ranging from cementoplasty to complex combined treatment associating thermoablation, cementoplasty and fixation. Many available manuscripts and reviews focus on the technical aspects, feasibility and outcomes of these procedures. However, not every procedure is suitable for every patient, and therefore selecting a patient for a specific procedure represents the first necessary step to a successful procedure. This review will describe every step of the selection process which the Interventional Radiologists is confronted with prior to performing a consolidation procedure in the setting of bone cancer. Defining the clinical setting is mandatory and includes assessing the patient's clinical status, cancer stage, level of pain and disability will help define the objective of the procedure: curative, palliative intent. A thorough imaging assessment is also mandatory, as it will define the type of consolidation (cementoplasty or fixation) which will be performed depending on the anatomical location and size of the lesion, the type of stresses at stake (compression or shear) and it will help plan the needle pathway and assess for possible complications. The process of selecting a patient for a specific procedure should be performed by the Interventional Radiologist but should be validated in a multidisciplinary approach. Moreover, the objective of a procedure, including the expected outcome and possible adverse events and complications should clearly be explained to the patient.