Contrast-enhanced ultrasound of the kidneys

\u3cp\u3eSeveral imaging techniques can be used for visualization of the kidneys dependent on the indication. Ultrasound (US), computerized tomography (CT), and magnetic resonance imaging (MRI) are most commonly used. US is a safe, relatively inexpensive, noninvasive, and widely available imaging method. It is therefore often used as a screening tool, especially for nephrolithiasis, hydronephrosis, renal masses, and perirenal processes. Often, in case of an abnormal finding, a CT or MRI follows for more detailed information about the extent, the anatomical landmarks, and eventually surgical treatment planning.\u3c/p\u3

Evaluation of renal masses with contrast-enhanced ultrasound

The clinical need for characterising small renal masses (SRMs) is increasing due to their rising incidental detection. This increase is especially seen in younger and older generations and concerns mainly SRMs. Diagnostics is mainly made by contrast-enhanced CT or MRI. However, these imaging methods fail to accurately distinguishing benign from malignant SRMs. Other disadvantages of CT or MRI are high costs, the use of ionizing radiation, nephrotoxicity induced by iodine contrast agents or nephrogenic systemic fibrosis (NSF) induced by gadolinium contrast agents. Contrast-enhanced ultrasound (CEUS) is based on ultrasonography and microbubbles to real-time visualize the renal blood flow without the use of nephrotoxic agents or ionizing radiation. This comprehensive review evaluates the capabilities of CEUS in the diagnostics of benign (angiomyolipomas, cysts, oncocytomas, pseudotumors) and malignant masses (renal cell carcinomas), and focuses on possible future treatment

Quality of life and perceived pain after laparoscopic-assisted renal cryoablation

Purpose: Assessing changes in quality of life (QoL) and perceived pain after laparoscopic-assisted cryoablation (LAC) of renal tumors. Patients and Methods: Data for 57 patients who were treated with LAC were prospectively collected. QoL, divided into various domains, and postoperative pain were assessed using the Medical Outcome Study 36-item Short Form Health Survey (SF-36), the European Organization for Research and Treatment of Cancer QLQ-C30 (EORTC-QLQ-C30), and Visual Analog Scale (VAS). Assessment was performed at baseline and at different time intervals until 1 year after LAC. Using a repeated measures analysis of variance, the influence of the following parameters was evaluated: Time of assessment, age, comorbidity, the occurrence of a complication, and tumor histology Results: SF-36: At baseline, only general health perceptions scored lower compared with the general population. Time of assessment and a complication did not affect QoL. Comorbidity and age >70 years led to a significantly lower QoL. Tumor histology affected general health perceptions. EORTC-QLQ-C30: Time of assessment affected 7 of 15 domains because of lower scores after 2 weeks. Age and comorbidity each negatively influenced five domains. A complication increased three symptoms scores and lowered general health status. Tumor histology significantly altered role functioning. VAS: VAS reached a peak 1 day after LAC, then quickly declined. Patients >70 years had significant higher VAS. Conclusions: QoL of patients who were treated with LAC showed a decrease 2 weeks after surgery but normalized to baseline within 3 months. Age and comorbidities especially affected QoL negatively. The VAS showed a peak 1 day after LAC and then quickly declined

Laparoscopic renal cryoablation using ultrathin 17-auge cryoprobes : mid-term oncological and functional results

OBJECTIVE To present the functional and oncological mid-term results of laparoscopic cryoablation of renal masses using third generation ultrathin (17-gauge[G]) cryoprobes. PATIENTS AND METHODS • Consecutive patients with small renal masses treated by cryoablation from September 2003 to September 2008 were prospectively evaluated. The cryoablation was performed using multiple third generation 17-G cryoprobes after intraoperative mass biopsy. • Data on serum creatinine measurements and cross sectional imaging (computed tomography/magnetic resonance imaging) were regularly collected according to a previously determined protocol. Follow-up was censored in October 2009. • Renal function analysis was based on estimated glomerular filtration rate (eGFR) at 1 year compared with baseline. Residual (or persistent tumour) and recurrence were defined as the presence of residual enhancement at first follow-up and ‘de novo’ enhancement of a non-enhancing cryolesion at any time during follow-up. • Survival data were analysed using the Kaplan–Meier method. Best estimates for the overall survival (OS), recurrence-free survival (RFS), cancer-specific survival (CSS) and metastatic-free survival (MFS) were made for patients with renal cell carcinoma (RCC) and for patients with RCC or non-diagnostic biopsy. RESULTS • A total of 92 patients (100 tumours; mean size 2.5 ± 0.8 cm) were treated in 95 sessions. The mean follow-up was 30.2 ± 16.6 months (Mean values are ±SD). • Intraoperative biopsy showed RCC in 51 patients (53.7%), benign lesion in 23 patients (24.2%) and was non-diagnostic in 21 patients (22.1%). Three tumour persistences and four radiological recurrences were detected. • The estimated mean RFS time and 3-year OS and RFS in patients with RCC exclusively were 47.8 (95% confidence interval [CI]: 44.1–51.1) months, 86.1% (95% CI: 71.2–93.6) and 91.8% (95% CI: 76.3–97.3), respectively. The figures were slightly higher in the group of patients with RCC or unknown pathology. The actual CSS and MFS rates were 100%. • Renal function was preserved in 84.5% of patients with normal preoperative eGFR. • Baseline eGFR was the only predictor of renal insufficiency development at 1-year follow-up. CONCLUSION Laparoscopic cryoablation with multiple ultrathin cryoprobes is oncologically and functionally effective at mid-term follow-up

What is the added value of combined core biopsy and fine needle aspiration in the diagnostic process of renal tumours?

Purpose Non-diagnostic results still hinder the routine use of core biopsy (CB) and fine needle aspiration (FNA) in the diagnostic process of renal tumours. Furthermore, substantial interobserver variability has been reported. We assessed the added value of combining the results of CB and FNA by five pathologists in the ex vivo diagnosis of renal mass. Methods Two ex vivo core biopsies were taken followed by two FNA passes from extirpated tumours. All samples were evaluated by five blinded pathologists. A consensus diagnosis of the surgical specimen was the index for comparison. For each pathologist, the number of non-diagnostic (non-conclusive or undetermined biology and failed biopsies), correct and incorrect scored cases of each technique was assessed. When a non-diagnostic CB or FNA had a correct diagnostic counterpart, this was considered as of added value. Results Of the 57 assessed tumours, 53 were malignant. CB was non-diagnostic in 4–10 cases (7–17.5%). FNA established the correct diagnosis in 1–7 of these cases. FNA was non-diagnostic in 2–6 cases (3.5–10.5%), and the counterpart CB established the correct diagnosis in 1–6 of these cases. For the 5 pathologists, accuracy of CB and FNA varied between 82.5–93% and 89.5–96.5%, respectively. Combination of both types of biopsy resulted in 55–57 correct results (accuracy 96.5–100%), i.e., an increase in accuracy of 3.5–14%. Conclusion Combining the result of CB and FNA in renal mass biopsy leads to a higher diagnostic accuracy. Recommendations on which technique used should be adapted to local expertise and logistic possibilities

Focal vs extended ablation in localized prostate cancer with irreversible electroporation; a multi-center randomized controlled trial

\u3cp\u3eBackground: Current surgical and ablative treatment options for prostate cancer (PCa) may result in a high incidence of (temporary) incontinence, erectile dysfunction and/or bowel damage. These side effects are due to procedure related effects on adjacent structures including blood vessels, bowel, urethra and/or neurovascular bundle. Ablation with irreversible electroporation (IRE) has shown to be effective and safe in destroying PCa cells and also has the potential advantage of sparing surrounding tissue and vital structures, resulting in less impaired functional outcomes and maintaining men's quality of life. Methods/Design: In this randomized controlled trial (RCT) on IRE in localized PCa, 200 patients with organ-confined, unilateral (T1c-T2b) low- to intermediate-risk PCa (Gleason sum score 6 and 7) on transperineal template-mapping biopsies (TTMB) will be included. Patients will be randomized into focal or extended ablation of cancer foci with IRE. Oncological efficacy will be determined by multiparametric Magnetic Resonance Imaging, Contrast-Enhanced Ultrasound imaging if available, TTMP and Prostate Specific Antigen (PSA) follow-up. Patients will be evaluated up to 5 years on functional outcomes and quality of life with the use of standardized questionnaires. Discussion: There is critical need of larger, standardized RCTs evaluating long-term oncological and functional outcomes before introducing IRE and other focal therapy modalities as an accepted and safe therapeutic option for PCa. This RCT will provide important short- and long-term data and elucidates the differences between focal or extended ablation of localized, unilateral low- to intermediate-risk PCa with IRE. Trial registration: Clinicaltrials.gov database registration number NCT01835977. The Dutch Central Committee on Research Involving Human Subjects registration number NL50791.018.14.\u3c/p\u3

Irreversible electroporation for the treatment of localized prostate cancer:a summary of imaging findings and treatment feedback

\u3cp\u3ePURPOSE: Imaging plays a crucial role in ablative therapies for prostate cancer (PCa). Irreversible electroporation (IRE) is a new treatment modality used for focal treatment of PCa. We aimed to demonstrate what imaging modalities can be used by descriptively reporting contrast-enhanced ultrasonography (CEUS), multiparametric magnetic resonance imaging (mpMRI), and grey-scale transrectal ultrasound (TRUS) results. Furthermore, we aimed to correlate quantitatively the ablation zone seen on mpMRI and CEUS with treatment planning to provide therapy feedback.\u3c/p\u3e\u3cp\u3eMETHODS: Imaging data was obtained from two prospective multicenter trials on IRE for localized low- to intermediate-risk PCa. The ablation zone volume (AZV) seen on mpMRI and CEUS was 3D reconstructed to correlate with the planned AZV.\u3c/p\u3e\u3cp\u3eRESULTS: Descriptive examples are provided using mpMRI, TRUS, and CEUS for treatment planning and follow-up after IRE. The mean AZV on T2-weighted imaging 4 weeks following IRE was 12.9 cm3 (standard deviation [SD]=7.0), 5.3 times larger than the planned AZV. Linear regression showed a positive correlation (r=0.76, P = 0.002). For CEUS the mean AZV was 20.7 cm3 (SD=8.7), 8.5 times larger than the planned AZV with a strong positive correlation (r=0.93, P = 0.001). Prostate volume is reduced over time (mean= -27.5%, SD=11.9%) due to ablation zone fibrosis and deformation, illustrated by 3D reconstruction.\u3c/p\u3e\u3cp\u3eCONCLUSION: The role of imaging in conjunction with IRE is of crucial importance to guide clinicians throughout the treatment protocol. CEUS and mpMRI may provide essential treatment feedback by visualizing the ablation zone dimensions and volume.\u3c/p\u3

The efficacy and safety of irreversible electroporation for the ablation of renal masses: a prospective, human, in-vivo study protocol

\u3cp\u3eBACKGROUND: Electroporation is a novel treatment technique utilizing electric pulses, traveling between two or more electrodes, to ablate targeted tissue. The first in human studies have proven the safety of IRE for the ablation of renal masses. However the efficacy of IRE through histopathological examination of an ablated renal tumour has not yet been studied. Before progressing to a long-term IRE follow-up study it is vital to have pathological confirmation of the efficacy of the technique. Furthermore, follow-up after IRE ablation requires a validated imaging modality. The primary objectives of this study are the safety and the efficacy of IRE ablation of renal masses. The secondary objectives are the efficacy of MRI and CEUS in the imaging of ablation result.\u3c/p\u3e\u3cp\u3eMETHODS/DESIGN: 10 patients, age ≥ 18 years, presenting with a solid enhancing mass, who are candidates for radical nephrectomy will undergo IRE ablation 4 weeks prior to radical nephrectomy. MRI and CEUS imaging will be performed at baseline, one week and four weeks post IRE. After radical nephrectomy, pathological examination will be performed to evaluate IRE ablation success.\u3c/p\u3e\u3cp\u3eDISCUSSION: The only way to truly assess short-term (4 weeks) ablation success is by histopathology of a resection specimen. In our opinion this trial will provide essential knowledge on the safety and efficacy of IRE of renal masses, guiding future research of this promising ablative technique.\u3c/p\u3e\u3cp\u3eTRIAL REGISTRATION: Clinicaltrials.gov registration number NCT02298608 . Dutch Central Committee on Research Involving Human Subjects registration number NL44785.018.13.\u3c/p\u3

The correlation between the electrode configuration and histopathology of irreversible electroporation ablations in prostate cancer patients

\u3cp\u3ePURPOSE: Irreversible electroporation (IRE) is a novel minimally invasive therapy for prostate cancer using short electric pulses to ablate prostate tissue. The purpose of this study is to determine the IRE effects in prostate tissue and correlate electrode configuration with the histology of radical prostatectomy (RP) specimens. We hypothesize that the area within the electrode configuration is completely ablated and that the area within the electrode configuration is predictive for the ablated area after treatment.\u3c/p\u3e\u3cp\u3eMETHODS: A prospective phase I/II study was conducted in 16 consecutive patients with histopathologically confirmed prostate cancer scheduled for RP. Focal or extended IRE treatment of the prostate was performed 4 weeks prior to RP. The locations of the electrodes were used to calculate the planned ablation zone. Following RP, the specimens were processed into whole-mount sections, histopathology (PA) was assessed and ablation zones were delineated. The area of the tissue alteration was determined by measuring the surface. The planned and the histological ablation zones were compared, analysed per individual patient and per protocol (focal vs. extended).\u3c/p\u3e\u3cp\u3eRESULTS: All cells within the electrode configuration were completely ablated and consisted only of necrotic and fibrotic tissue without leaving any viable cells. The histological ablation zone was always larger than the electrodes configuration (2.9 times larger for the 3 electrodes configuration and 2.5 times larger for the ≥4 electrode configuration). These ablation effects extended beyond the prostatic capsule in the neurovascular bundle in 13 out of 15 cases.\u3c/p\u3e\u3cp\u3eCONCLUSIONS: IRE in prostate cancer results in completely ablated, sharply demarcated lesions with a histological ablation zone beyond the electrode configuration. No skip lesions were observed within the electrode configuration.\u3c/p\u3e\u3cp\u3eCLINICAL TRIALS: ClinicalTrials.gov Identifier: NCT01790451 https://clinicaltrials.gov/ct2/show/NCT01790451.\u3c/p\u3

The safety and efficacy of irreversible electroporation for the ablation of prostate cancer: a multicentre prospective human in vivo pilot study protocol

Current surgical and ablative treatment options for prostate cancer have a relatively high incidence of side effects, which may diminish the quality of life. The side effects are a consequence of procedure-related damage of the blood vessels, bowel, urethra or neurovascular bundle. Ablation with irreversible electroporation (IRE) has shown to be effective in destroying tumour cells and harbours the advantage of sparing surrounding tissue and vital structures. The aim of the study is to evaluate the safety and efficacy and to acquire data on patient experience of minimally invasive, transperineally image-guided IRE for the focal ablation of prostate cancer. In this multicentre pilot study, 16 patients with prostate cancer who are scheduled for a radical prostatectomy will undergo an IRE procedure, approximately 30 days prior to the radical prostatectomy. Data as adverse events, side effects, functional outcomes, pain and quality of life will be collected and patients will be controlled at 1 and 2 weeks post-IRE, 1 day preprostatectomy and postprostatectomy. Prior to the IRE procedure and the radical prostatectomy, all patients will undergo a multiparametric MRI and contrast-enhanced ultrasound of the prostate. The efficacy of ablation will be determined by whole mount histopathological examination, which will be correlated with the imaging of the ablation zone. The protocol is approved by the ethics committee at the coordinating centre (Academic Medical Center (AMC) Amsterdam) and by the local Institutional Review Board at the participating centres. Data will be presented at international conferences and published in peer-reviewed journals. This pilot study will determine the safety and efficacy of IRE in the prostate. It will show the radiological and histopathological effects of IRE ablations and it will provide data to construct an accurate treatment planning tool for IRE in prostate tissue. Clinicaltrials.gov database: NCT0179045