Percutaneous Ablation Procedures Research Articles

The Added Value of Transcatheter CT Hepatic Angiography (CTHA) Image Guidance in Percutaneous Thermal Liver Ablation: An Experts' Opinion Pictorial Essay.

With the rapidly evolving field of image-guided tumor ablation, there is an increasing demand and need for tools to optimize treatment success. Known factors affecting the success of (non-)thermal liver ablation procedures are the ability to optimize tumor and surrounding critical structure visualization, ablation applicator targeting, and ablation zone confirmation. A recent study showed superior local tumor progression-free survival and local control outcomes when using transcatheter computed tomography hepatic angiography (CTHA) guidance in percutaneous liver ablation procedures. This pictorial review provides eight clinical cases from three institutions, MD Anderson (Houston, TX, USA), Gustave Roussy (Paris, France), and Amsterdam UMC (Amsterdam, The Netherlands), with the intent to demonstrate the added value of real-time CTHA guided tumor ablation for primary liver tumors and liver-only metastatic disease. The clinical illustrations highlight the ability to improve the detectability of the initial target liver tumor(s) and identify surrounding critical vascular structures, detect 'vanished' and/or additional tumors intraprocedurally, differentiate local tumor progression from non-enhancing scar tissue, and promptly detect and respond to iatrogenic hemorrhagic events. Although at the cost of adding a minor but safe intervention, CTHA-guided liver tumor ablation minimizes complications of the actual ablation procedure, reduces the number of repeat ablations, and improves the oncological outcome of patients with liver malignancies. Therefore, we recommend adopting CTHA as a potential quality-improving guiding method within the (inter)national standards of practice.

PET/CT-Guided Tumor Ablation, From the AJR "How We Do It" Special Series.

PET/CT guidance during percutaneous tumor ablation procedures combines metabolic and anatomic imaging, providing a powerful approach that can improve intraprocedural tumor visibility and ablation margin evaluation for a variety of cancers. This article reviews key advantages of the use of PET/CT as guidance for tumor ablation and describes the authors' technique for performing such procedures, highlighting the application of PET/CT for each procedural stage, including planning, targeting, monitoring, and assessment of results. Practical considerations in establishing and operating an interventional PET/CT practice are discussed. Suggestions for overcoming logistical challenges that have historically limited procedural PET/CT adoption are proposed. Several emerging procedural approaches relating to PET/CT and other molecular or anatomic imaging technologies are briefly explored.

Multimodal Management of Colorectal Liver Metastases: State of the Art.

Liver is the most common site of colorectal cancer (CRC) metastases. Treatment of CRC liver metastases (CRLM) includes different strategies, prevalently based on the clinical and oncological intent. Valid approaches in liver-limited or liver-prevalent disease include surgery, percutaneous ablative procedures (radiofrequency ablation, microwave ablation), intra-arterial perfusional techniques (chemo-embolization, radio-embolization) as well as stereotactic radiotherapy. Systemic treatments, including chemotherapy, immunotherapy and other biological agents, are the only options for patients with no chance of locoregional approaches. The use of chemotherapy in other settings, such as neoadjuvant, adjuvant or conversion therapy of CRLM, is commonly accepted in the clinical practice, although data from several clinical trials have been mostly inconclusive. The optimal integration of all these strategies, when applicable and clinically indicated, should be ever considered in patients affected by CRLM based on clinical evidence and multidisciplinary experience. Here we revised in detail all the possible therapeutic approaches of CRLM focusing on the current evidences, the studies still in progress and the often contradictory data.

Ablación percutánea de tumores en la cúpula hepática asistida por sistemas de navegación para TC. Descripción técnica y experiencia inicial

Introduction and objectiveCT navigation systems enable access to lesions that are in difficult locations, with poor ultrasound visualisation, and adjacent to vulnerable structures. The objective of this study is to show how navigation systems can increase safety and precision in the ablative treatment of lesions in the hepatic dome. Materials and methodsA retrospective single-centre study was carried out from April 2018 to February 2022. Percutaneous ablation procedures were performed with CT-navigation system assistance on 75 patients, of which 18 had lesions in the hepatic dome (16 HCCs and 5 metastatic tumours). Syngo.via VB30 software was used to analyse the volume of lesions and ablation areas in pre- and post-treatment CT images. Technical success was determined 24hours following the procedure and according to the length of time free from tumour viability (through imaging tests every three months). ResultsA volumetric study was carried out for 20 of the 21 lesions (95%) and technical success was achieved in 11 of the 21 lesions (52%). In 9 of the 12 lesions that completed a year of follow-up (75%), no signs of tumour viability were detected, achieving local control of the disease. Furthermore, in 5 of these 9 lesions (56%) no progression was observed in other locations of the liver. The syngo.via software version VB30 was able to predict the area of recurrence in 71% of cases. No permanent side effects or death were secondary to the procedure. ConclusionCT navigation systems provide increased safety and precision in the percutaneous ablative treatment of tumours in the hepatic dome, making this technique a good treatment option.

Cryothermal energy demonstrates shorter ablation time and lower complication rates compared with radiofrequency in surgical hybrid ablation for recurrent ventricular tachycardia

Recurrent ventricular tachycardia (VT) after prior endocardial catheter ablation(s) presents challenges in the setting of prior cardiac surgery where percutaneous epicardial access may not be feasible. The purpose of this study was to compare the outcomes of cryothermal vs radiofrequency ablation in direct surgical epicardial access procedures. We performed a retrospective study of consecutive surgical epicardial VT ablation cases. Surgical cases using cryothermal vs radiofrequency ablation were analyzed and outcomes were compared. Between 2009 and 2022, 43 patients underwent either a cryothermal (n = 17) or a radiofrequency (n = 26) hybrid epicardial ablation procedure with direct surgical access. Both groups were similarly matched for age, sex, etiology of VT, and comorbidities with a high burden of refractory VT despite previous endocardial and/or percutaneous epicardial ablation procedures. The surgical access site was lateral thoracotomy (76.5%) in the cryothermal ablation group compared with lateral thoracotomy (42.3%) and subxiphoid approach (38.5%) in the radiofrequency group, with the remainder in both groups performed via median sternotomy. The ablation time was significantly shorter in those undergoing cryothermal ablation vs radiofrequency ablation (11.54 ± 15.5 minutes vs 48.48 ± 23.6 minutes; P < .001). There were no complications in the cryothermal ablation group compared with 6 patients with complications in the radiofrequency group. Recurrent VT episodes and all-cause mortality were similar in both groups. Hybrid surgical VT ablation with cryothermal or radiofrequency energy demonstrated similar efficacy outcomes. Cryothermal ablation was more efficient and safer than radiofrequency in a surgical setting and should be considered when surgical access is required.

Outpatient percutaneous image-guided microwave ablation with monitored anesthesia care: An exploratory study

PurposeTo evaluate the feasibility, safety, and periprocedural perception of pain for a combination approach of moderate and deep sedation for image-guided percutaneous microwave ablation of both primary and secondary malignant lesions. MethodsThis was a retrospective study of 33 image-guided percutaneous microwave ablation procedures performed on 33 patients in an outpatient-based interventional radiology center. We used a combination of midazolam, fentanyl, propofol, and/or ketamine to achieve mild to moderate sedation for the procedure, and also to achieve deeper sedation as needed for the ablation portion. ResultsTechnical success was achieved in all image-guided percutaneous microwave ablation procedures. Mean procedural time was 49.4 min. There were no major complications. Intraprocedural pain was absent in all patients. All 33 patients were deemed fit for discharge within 30 min following the procedure. ConclusionThe combination approach of moderate and deep sedation for anesthesia during image-guided percutaneous microwave ablation is an advantageous option. This approach has a strong safety profile, good technical success, short procedure times, low levels of intraprocedural and post-procedural pain, and short recovery from anesthesia.

Predicting Infectious Complications after Percutaneous Thermal Ablation of Liver Malignancies: A 12-year Single-Center Experience.

Background Infectious complications after percutaneous thermal ablation are seldom discussed, but better understanding of risk factors and early prediction is critical. Purpose To estimate the incidence of infectious complications after percutaneous thermal ablation of liver malignancies and to develop prediction models. Materials and Methods This single-center retrospective study reviewed the data of 3167 patients who underwent 7545 percutaneous US-guided thermal ablation procedures of liver malignancies between January 2010 and January 2022. All procedures with infectious complications were included as the case group. For each case, one treatment date-matched control subject without infection was randomly selected following a nested case-control design. Independent factors of overall and hepatobiliary infection were investigated with multivariable logistic regression. Results A total of 80 patients (median age, 59 years; IQR, 51-68 years; 64 men, 16 women) developed infectious complications after 80 ablation procedures; the incidence was 1.1% (80 of 7545 procedures). Of those with infection, 18% (14 of 80 patients) were severe, and 10% (eight of 80 patients) died as a result. Independent risk factors for overall infectious complication included prior biliary intervention (odds ratio [OR], 18.6; 95% CI: 4, 86; P < .001), prior transarterial chemoembolization (TACE) (OR, 2.4; 95% CI: 1.0, 5.8; P = .045), and the largest tumor size (OR, 1.9; 95% CI: 1.3, 2.8; P = .002); on this basis, subcapsular location was an additional risk factor of hepatobiliary infection. Prediction models for overall and hepatobiliary infection had an area under the receiver operating characteristics curve (AUC) of 0.77 and 0.82, respectively, both of which showed better AUC compared with the models, including prior biliary intervention alone (AUC = 0.63 and 0.65, respectively; P = .01 and P = .005, respectively). Conclusion Infectious complications after percutaneous thermal ablation of liver malignancies were uncommon but potentially fatal. Independent predictors were prior biliary intervention, prior transarterial chemoembolization, and the largest tumor size. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Ben-Arie and Sosna in this issue.

The potential role of a narrow foramen rotundum and foramen ovale in the development of concomitant continuous pain in trigeminal neuralgia

The most characteristic symptom of trigeminal neuralgia (TN) is paroxysmal and lancinating pain along the sensory distribution of the trigeminal nerve. Notably, a proportion of TN patients also experience persistent throbbing or burning in the same territory as their paroxysmal pain, termed concomitant continuous pain (CCP). The neurovascular compression (NVC) theory has been regarded as the primary cause of paroxysmal pain in TN. In contrast, the mechanisms underlying CCP can hardly be explained by NVC and have yet to be clearly elucidated. Both the foramen rotundum (FR) and foramen ovale (FO) are substantial bony apertures in the middle cranial fossa, through which the second (V2) and third divisions (V3) of the trigeminal nerve pass, respectively. Prior studies have proposed that a narrow FR and FO on the right side may result in a greater incidence of right-sided symptoms and be involved in the development of TN. However, given the nature of CCP and certain anatomical findings, we postulate that secondary compression of V2 and V3 by narrow foramina is more likely to be the primary cause of the persistent pain instead of the paroxysmal pain in cases of TN with CCP. TN with CCP may be the combination of trigeminal neuralgia induced by NVC and trigeminal neuropathic pain resulting from constant entrapment of V2 and V3. Therefore, considering that microvascular decompression cannot resolve all causes of TN with CCP, percutaneous ablative procedures and stereotactic radiosurgery may be more appropriate for patients with narrow foramina.

Renal Mass Biopsy Mandate Is Associated With Change in Treatment Decisions.

To prevent avoidable treatment and make more informed care decisions about small renal masses, the use of renal mass biopsies has increased since the early 2000s. In April 2017, Atrium Health Carolinas Medical Center began requiring biopsies before all percutaneous thermal ablation procedures for renal masses. We aim to determine the effect of this preablation biopsy mandate on small renal mass treatment decisions. Our study is a retrospective analysis of a prospectively managed database designed to track patients with small renal masses presented at the Kidney Tumor Program from 2000-2020. We separated patients into 2 cohorts (pre- and postmandate) based on the initial encounter date, excluding those from April 2017-April 2018 to allow for implementation of the mandate. We also excluded patients with masses >4 cm. Overall, we found no significant difference between the pre- and postmandate cohorts, with race as an exception. Implementation of the mandate coincided with an increase in biopsies for both ablation and nonablation treatment pathways (P < .001, P = .01). Renal mass biopsy rates increased in all socioeconomic groups except the lowest quartile. Additionally, Black/Hispanic patients had the highest biopsy rate. We found significant changes in treatment decisions between our cohorts: surgery decreased 24% (P < .001), active surveillance increased 28% (P < .001), and patients with no follow-up decreased 8% (P = .03). Our data indicate that a preablation renal mass biopsy mandate is associated with the wider use of biopsies for all small renal mass patients, fewer surgical interventions, and an increase in active surveillance.

Safety of High-Frequency Jet Ventilation During Image-Guided Thermal Ablation Procedures.

Percutaneous thermal ablative technique is a common radiological procedure for malignant lesions treatment. Controlled assisted ventilation during general anesthesia is the usual mode of ventilation, but high-frequency jet ventilation (HFJV) can be a helpful alternative for the operator. The objective was to evaluate the safety of HFJV during thermal ablation procedures. This monocentric prospective analysis included adult patients undergoing percutaneous thermal ablation procedures for abdominal tumor performed under HFJV. Procedures with a transpulmonary path were excluded. The primary outcome was the incidence of respiratory complications. Secondary outcomes included gas exchange modifications (hypercapnia, hypoxemia, pulmonary atelectasis) and the incidence of barotrauma. Sixty patients were included during the study period. The mean duration time was 88min. All procedures went according to the protocol and there was no respiratory complication. There was no barotrauma event. Three patients had an exhaled capnia above 45mmHg at the end of the procedure which normalized within 10min of conventional ventilation. HFJV during thermal ablation procedures is safe regarding gas exchange and barotrauma. This technique could be an interesting alternative to conventional ventilation during image-guided thermal ablation procedures. Clinical Trials database This study was registered in Clinical Trials database (NCT04209608).

Endoscopic transection of right L3 and L4 medial branch nerves and L5 dorsal ramus: A 2-dimensional operative video

Zygapophyseal joints in the lumbar spine are innervated by medial branches of the dorsal rami of spinal nerves and have been implicated in the generation of axial low back pain. Percutaneous radiofrequency ablation procedures target bony landmarks under fluoroscopic guidance near the anticipated location of medial branches and dorsal rami. In contrast, endoscopic visualization allows for surgical transection of the targeted nerves through either direct visualization or dissection and ablation of the tissues surrounding the expected trajectory of the nerves. Endoscopic transection of medial branches and dorsal rami has been suggested as a possible alternative to percutaneous radiofrequency lesioning although further research is needed to define indications, explore relative risks and benefits, and evaluate efficacy by directly comparing these two techniques. In this video, we present a case of a female with chronic axial low back pain that was refractory to conservative care including physical therapy, exercise, facet steroid injections, and analgesic medications. After positive response to blocking the L3, L4 medial branch nerves and the L5 dorsal ramus, the patient underwent multiple percutaneous radiofrequency ablations, which provided progressively shorter duration of relief. With her persistent symptoms suggestive of facet-mediated lumbar back pain, endoscopic transection was offered as an alternative approach. We provide an operative video including discussion of imaging, target anatomy and operative steps for endoscopically-visualized transection of the L3 and L4 medial branch nerves and the L5 dorsal ramus on the right side.

In-Circuit High-Frequency Jet Ventilation for Radiological Tumor Ablation: A Case Series.

High-frequency jet ventilation (HFJV) can reduce organ movement that otherwise complicates percutaneous image-guided ablation (IGA) procedures. This study describes feasibility and safety of the technique in routine use. We describe our method for the use of HFJV and present 169 consecutive cases, including IGA of tumors of the lung, liver, kidney, and pancreas. Intended oncological treatment was delivered in all cases and HFJV used for the duration of treatment in all except one case. We describe the characteristics of patients, procedures, and adverse events. It is feasible to use HFJV as the routine standard of care for IGA.

Abstract No. 132 Trends in percutaneous ablation procedures among Medicare patients from 2010-2018: an analysis of procedure volume, specialty involvement, and reimbursement rates

The use of percutaneous ablative techniques in the treatment of a variety of cancers and benign tumors is well documented with research supporting effective outcomes in appropriately selected patients. The following provides an overview of ablations performed for Medicare Beneficiaries by organ system.

Update on Percutaneous Local Ablative Procedures for the Treatment of Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the fifth most common tumor worldwide. Because many hepatocellular carcinomas are already unresectable at the time of initial diagnosis, percutaneous tumor ablation has become established in recent decades as a curative therapeutic approach for very early (BCLC 0) and early (BCLC A) HCC. The aim of this paper is to provide a concise overview of the percutaneous local ablative procedures currently in use, based on their technical characteristics as well as clinical relevance, taking into account the current body of studies. The literature search included all original papers, reviews, and meta-analyses available via MEDLINE and Pubmed on the respective percutaneous ablation procedures; the primary focus was on randomized controlled trials and publications from the last 10 years. Radiofrequency ablation (RFA) and microwave ablation (MWA) are well-established procedures that are considered equal to surgical resection in the treatment of stage BCLC 0 and A HCC with a diameter up to 3 cm due to their strong evidence in international and national guidelines. For tumors with a diameter between 3 and 5 cm, the current S3 guidelines recommend a combination of transarterial chemoembolization (TACE) and thermal ablation using RFA or MWA as combination therapy is superior to thermal ablation alone in tumors of this size and shows comparable results to surgical resection in terms of overall survival. Alternative, less frequently employed thermal procedures include cryotherapy (CT) and laser ablation (LA). Non-thermal procedures include irreversible electroporation (IRE), interstitial brachytherapy (IBT), and most recently, electrochemotherapy (ECT). Due to insufficient evidence, these have only been used in individual cases and within the framework of studies. However, the nonthermal methods are a reasonable alternative for ablation of tumors adjacent to large blood vessels and bile ducts because they cause significantly less damage to these structures than thermal ablation methods. With advances in the technology of the respective procedures, increasingly good evidence, and advancements in supportive techniques such as navigation devices and fusion imaging, percutaneous ablation procedures may expand their indications for the treatment of larger and more advanced tumors in the coming years. · RFA and MWA are considered equal to surgical resection asa first-line therapy for the curative treatment of stage BCLC 0 and A HCCs with a diameter of up to 3 cm.. · For HCCs with a diameter between 3 and 5 cm, a combination of TACE and RFA or MWA is recommended. This combination therapy yields results comparable to those ofsurgical resection in terms of overall survival.. · Due to insufficient evidence, alternative ablation methods have only been used in individual cases and within the framework of studies. However, nonthermal methods, such as IRE, IBT, and, most recently, ECT, are a reasonable alternative for ablation of HCCs adjacent to large blood vessels and bile ducts because they cause significantly lessdamage to these structures than thermal ablation methods.. · Luerken L, Haimerl M, Doppler M et al. Update on Percutaneous Local Ablative Procedures for the Treatment of Hepatocellular Carcinoma. Fortschr Röntgenstr 2022; 194: 1075 - 1086.

Utility of the RENAL Nephrometry Scoring System in Predicting Adverse Events and Outcomes of Percutaneous Microwave Ablation of Renal Tumors

PurposeTo assess the utility of the radius, exophytic/endophytic, nearness to collecting system or sinus, anterior/posterior, and location relative to polar lines (RENAL) nephrometry scoring system at predicting adverse events and outcomes in percutaneous microwave ablation (MWA) of renal tumors. Materials and MethodsA retrospective review of 116 patients who underwent MWA from 2004 to 2018 at 2 large university hospitals was conducted. Patient demographics and tumor characteristics were collected. The RENAL nephrometry scores were calculated, and procedure-related adverse events were stratified into minor and major (the Society of Interventional Radiology classification of class C or higher). Technical and oncologic outcomes were based on follow-up magnetic resonance imaging and computed tomography scans after ablation. ResultsThe mean RENAL score was 6.6 (range, 4–11), and the mean tumor size was 24 mm. Follow-up ranged between 16 and 161 weeks (median, 50 weeks; mean, 65 weeks). Oncologic control was achieved in 96% (n = 111) of patients. The major and minor adverse event rates were 8.6% (n = 10) and 17% (n = 19), respectively. The mean RENAL score for patients with recurrent and/or residual tumor (8.2 ± 2.7) was higher than that for patients without disease recurrence (6.5 ± 3.5, P = .05). However, in a multivariate analysis, the RENAL score was not found to be an independent predictor of oncologic outcomes (odds ratio, 1.548; P = .092). ConclusionsThe RENAL nephrometry score has minimal utility for predicting outcomes and adverse events in MWA of renal tumors. The inconsistent nature of RENAL nephrometry scoring in percutaneous ablation procedures underscores the need for an ablation-specific risk stratification system.

Przetoka przedsionkowo-przełykowa – stan kliniczny oraz historia choroby jako klucz do postawienia rozpoznania w badaniu obrazowym

Atrioesophageal fistula is an extremely rare, but a life-threatening complication of percutaneous ablation. With an increasing prevalence of atrial fibrillation and increasing number of percutaneous ablation procedures following it, awareness of catheter ablation complications and their detection should be raised. A 69-year-old male, with history of atrial fibrillation admitted with a suspicion of a stroke. The patient was treated with percutaneous ablation 27 days earlier in a different hospital. On admission, in addition to the neurological symptoms, moderately increased inflammatory markers and a low grade fever were found. During the hospitalisation, a prompt inflammatory markers elevation was observed and the patient’s condition had gradually worsened. Sepsis was diagnosed and a broad spectrum antibiotic therapy was administered. On the 6th day of hospitalisation the patient went into cardiac arrest. Cardiopulmonary resuscitation was successful and return of spontaneous circulation occurred. An electrocardiogram showed changes typical for ST elevation myocardial infarction. Emergent coronary angiogram showed no significant stenosis in any of the coronary arteries. In a follow-up brain NECT air emboli were detected. A chest NECT was performed and revealed free gas within the left atrium and in pericardial cavity, which in juxtaposition with the patient’s medical history suggested presence of an atrioesophageal fistula. Despite all taken measures the patient died. An autopsy confirmed atrioesophageal fistula connecting oesophagus with left atrium. The purpose of this case is to raise awareness of percutaneous ablation complications among both clinicians and radiologists. It emphasizes how crucial precise clinical data and imaging exams are in diagnosing atrioesophageal fistula.

An infant phantom for pediatric pericardial access and electrophysiology training.

BackgroundCardiac procedures in infants and children require a high level of skill and dexterity owing to small stature and anatomy. Lower incidence of procedure volume in this population results in fewer clinical opportunities for learning. Simulators have grown in popularity for education and training, though most existing simulators are often cost-prohibitive or model adult anatomy.ObjectiveDevelop a low-cost simulator for practicing the skills to perform percutaneous pericardial access and cardiac ablation procedures in pediatric patients.MethodsWe describe 2 simulators for practicing cardiac procedures in pediatric patients, with a total cost of less than $500. Both simulators are housed within an infant-size doll. The first simulator is composed of an infant-size heart and a skin-like covering to practice percutaneous pericardial access to the heart. Participants obtained sheath access to the heart under direct visualization. The second simulator houses a child-size heart with 7 touch-activated targets to practice manipulating a catheter through a small heart. This can be performed under direct visualization and with 3-dimensional mapping via CARTO. Participants manipulated a catheter to map the heart by touching the 6 positive targets, avoiding the negative target.ResultsPhysicians-in-training improved their time to complete the task between the first and second attempts. Physicians experienced with the tools took less time to complete the task than physicians-in-training.ConclusionThis inexpensive simulator is anatomically realistic and can be used to practice manipulating procedure tools and develop competency for pediatric cardiac procedures.

Abstract No. 505 Validating the registration accuracy of a multimodal registration device to enhance computed tomography–guided percutaneous biopsy and ablation procedures

CT-guided biopsy and ablation procedures are commonly performed for diagnosis and treatment of abdominal tumors. However, targeting soft tissue lesions using low-resolution CT-fluoroscopy can be technically challenging due to limited visualization. The purpose of this study is to assess the accuracy of IGTFusion, an FDA-cleared device capable of performing real-time, nonrigid, multimodal image registration for targeting assistance, in the registration of pre-procedural abdominal CT with intra-procedural CT-fluoroscopy scans.

Ventilatory Effect of Midazolam in Propofol Deep Sedation for Hepatic Tumor Patients Undergoing Percutaneous Radiofrequency Ablation Procedure

Objective: The aim of the study was to compare the ventilatory effect between propofol deep sedation technique with and without midazolam in hepatic tumor patients undergoing radiofrequency ablation procedure. Methods: Three hundred and seventy-four patients who underwent radiofrequency ablation procedure in a single year were randomly assigned to the deep sedation without midazolam group (A, n = 187) and deep sedation with midazolam group (B, n = 187). Patients in group A received normal saline, and those in group B received 0.02 mg/kg of midazolam intravenously in equivalent volume. All patients were oxygenated with 100% O2 via nasal cannula and sedated with intravenous fentanyl and the titration of intravenous propofol. Ventilatory parameters, including oxygen saturation, end tidal carbon dioxide, and respiratory rate every five minutes, during and after the procedure, as well as the duration of sleep and sedation score in the recovery room, were recorded. Results: There were no significant differences in the patients’ characteristics, duration of procedure, total dose of propofol, ventilatory parameters including oxygen saturation, end tidal carbon dioxide, and respiratory rate, as well as sedation score at 20, 25, 30, 35, and 40 min after the procedure, between the two groups. However, mean sedation score at 5, 10, and 15 min after the procedure, in group B, was significantly lower than in group A. In addition, the duration of sleep after the procedure, in group B, was significantly greater than in group A. No serious ventilatory adverse effects were observed either group. Conclusion: Propofol deep sedation with and without midazolam for hepatic tumor patients who underwent radiofrequency ablation procedure was safe and effective. A low dose of midazolam in propofol deep-sedation technique did not create serious ventilatory effects.

Recent Imaging Advancements for Lung Metastases in Children with Sarcoma.

In children and adolescents affected by musculoskeletal sarcomas (both soft tissue and bone sarcomas), the presence of lung metastases is a frequent complication, that should be known since the patient's prognosis, as management, and treatment depend on it. During the staging phase, the detection of lung metastases should be sensitive and specific, and it should be carried out by minimizing the radiation exposure. To deal with this problem, imaging has reached important goals in recent years, thanks to the development of cone-beam CT or low-dose computed tomography, with some new iterative reconstruction methods, such as Veo and ASIR. Imaging is also fundamental for the possibility to perform lung biopsies under CT guidance, with less morbidity, less time-consumption, and shorter recovery time, compared to surgical biopsies.Moreover, important results have also been demonstrated in the treatment of lung metastases, due to the improvement of new mini-invasive image-guided percutaneous thermal ablation procedures, which proved to be safe and effective also in young patients.