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Preprocedure enhanced CT shows a mixed solid and cystic enhancing posterior renal tumor (6 o'clock in kidney).
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Fusion technology with electromagnetic (EM) tracking enables navigation with multimodality feedback that lets the operator use different modalities during different parts of the image-guided procedure. This may be particularly helpful in patients with renal insufficiency undergoing kidney tumor ablation, in whom there is a desire to minimize or avo...
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Context 1
... CT scan did not adequately visualize the tumor (Figure 4(c)), and contrast was not desirable due to renal insufficiency. MR (Philips 3.0T Achieva scanner, Philips Medical Systems, Best, The Netherlands) with gadolinium- DTPA contrast (Magnevist; Berlex Laboratories, Wayne, NJ, USA) and preprocedure enhanced CT showed the tumor margins well (Figure 1). An EM tracking system and field generator were used ( Figure 2) (Northern Digital Inc., Waterloo, ON, USA) interfaced with custom registration and display software (Philips Research, Briarcliff, NY, USA) and a commercially available tracked 22 G stylet inside a standard 19 G outer biopsy guider needle stylet (Philips Healthcare, Toronto, ON, USA). ...Similar publications
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Citations
... US is readily accessible and commonly used for TA, providing real-time guidance. Fusion imaging combines US with pre-treatment CT or MRI, and can ameliorate targeting and intra-procedural ablation monitoring [72]. Disadvantages include dependence on user expertise and poor visualization of the renal mass, particularly in patients with large body habitus or overlying bowel gas. ...
Ablative (percutaneous and stereotactic) thermal and radiotherapy procedures for management of both primary and metastatic renal cell carcinoma are increasing in popularity in clinical practice. Data suggest comparable efficacy with lower cost and morbidity compared to nephrectomy. Ablative therapies may be used alone or in conjunction with surgery or chemotherapy for treatment of primary tumor and metastatic disease. Imaging plays a crucial role in pre-treatment selection and planning of ablation, intra-procedural guidance, evaluation for complications, short- and long-term post-procedural surveillance of disease, and treatment response. Treatment response and disease recurrence may differ considerably after ablation, particularly for stereotactic radiotherapy, when compared to conventional surgical and chemotherapies. This article reviews the current and emerging role of imaging for ablative therapy of renal cell carcinoma.
... Being widely tested in liver ablations [4,5], fusion imaging for renal percutaneous interventions is still in its infancy [6]. No clinical series have been published yet [7,8] and only a single case report has previously described the use of US/CBCT imaging to assist renal ablation [9]. The role of CT as a modality to guide renal ablation was recently defined in the CIRSE guidelines published in 2017 [10]. ...
... The benefit of US/CBCT fusion imaging has already been postulated in some recent narrative review papers [17,18]. Although described sporadically in the clinical practice [7,9], a feasibility study for its use as image-guidance for renal ablation is still lacking. Based on the experience gained on focal hepatic lesions [5,19,20], we assumed fusion imaging might improve the detection of poorly visible lesions on US. ...
IntroductionFusion imaging is gaining attention as an imaging technique to assist minimally invasive tumour ablation. Ultrasound (US) and computed tomography (CT) are the most common imaging modalities to guide thermal ablation of renal tumours, yet cone-beam CT (CBCT) has recently been described to successfully assist percutaneous renal interventions. Our goal was to evaluate primary technical success and correct lesion targeting of US/CBCT fusion imaging to guide the ablation of kidney masses < 2 cm in a small group of patients.Material and methodsSix renal lesions (maximum diameter 11–17 mm) were treated with RFA in 5 different patients using real-time US/CBCT. Fusion imaging was used to identify and monitor tumour ablation. Demographics, tumour characteristics and mean serum creatinine levels were recorded before and after the procedure. Primary technical success and correct lesion targeting represented the main endpoints of the study. Primary technique efficacy was confirmed at 1-month and 3-month contrast-enhanced CT follow-ups.ResultsIn all cases, a confident US/CBCT synchronisation was reached and allowed for a correct targeting and a successful percutaneous ablation. Primary technique efficacy was 100%. No recurrence was observed at the follow-up that ranged from 8 to 26 months (mean 16 months).ConclusionsUS/CBCT fusion proved to be a viable method to precisely guide safe and effective percutaneous thermal ablation in patients with small renal tumours, especially when hardly detectable on US.Key Points
• US/CBCT fusion imaging for renal ablation is safe and feasible.
• US/CBCT fusion imaging allows for an improved targeting and complete ablation of small RCC with poor US-conspicuity.
... Thanks to recent technological development, it is nowadays possible to fuse datasets deriving from different imaging modalities, and thus to perform ablation under the guidance of fusion imaging [11][12][13]. This technology is nowadays more and more applied in the guidance of thermal ablations, particularly in the liver, while experiences in the kidney are still limited [14][15][16][17]. Particularly, fusion imaging might be particularly useful when the target lesion is completely invisible or poorly visible at ultrasound (US) [15,18], as in the case of a small renal lesion with the same echogenicity of surrounding renal parenchyma. ...
... Systems for real-time image fusion of US and CT have been commercially available for some years, and have been applied in the abdomen, particularly in the treatment of liver tumors, and seems to be particularly useful in the treatment of difficult lesions or not well visible lesions [15,18,28]. Limited reports are present in the literature regarding their application in the guidance of ablation of renal lesions [16,17]. In 2012 Amalou et al., reported the first case of a patient with Von Hippel Lindau disease and recurrent renal tumor successfully treated with percutaneous ablation guided by image fusion [17]. ...
... Limited reports are present in the literature regarding their application in the guidance of ablation of renal lesions [16,17]. In 2012 Amalou et al., reported the first case of a patient with Von Hippel Lindau disease and recurrent renal tumor successfully treated with percutaneous ablation guided by image fusion [17]. One possible advantage arising from the application of fusion imaging in the renal ablation scenario would be the possibility to reduce the number of CT scans that would be otherwise required to correctly deploy the needle in the target lesion with the CT alone as guidance. ...
Purpose
To assess the capability of ultrasound-computed tomography (US-CT) fusion imaging to guide a precise targeting of renal tumors invisible or poorly visible with US
Materials and methods
From 2016 renal tumors poorly visible or inconspicuous/invisible at US were treated at our institution with the guidance of US/CT fusion in a room equipped with CT scanner. Feasibility of the procedure, accuracy of targeting, complications, and technique efficacy were evaluated.
Results
Of 227 patients treated from 2016 to March 2020, 91 patients (65 males and 26 females, mean age 68.5 ± 10.1 years) with 97 renal lesions (mean maximum diameter 21.6 ± 9.4 mm) inconspicuous/invisible (29/97, 29.9%) or poorly visible (68/97, 70.1%) at US underwent treatment under US-CT fusion guidance. US-CT fusion imaging guidance was always technically feasible and enabled correct targeting in 97/97/(100%) of cases. Technical success was achieved in 93/97 lesions (95.9%). Three lesions were retreated during the same ablative session, while 1 was retreated in a subsequent session. Thus, primary efficacy was achieved in one session in 96/97 (98.9%) cases and secondary efficacy in 97/97 (100%) cases
Conclusion
US-CT image fusion guidance allows for a correct tumor targeting of renal tumors poorly visible or inconspicuous/invisible with US alone, with a high rate of technical success and technique efficacy.
... For this reason, in our center, we started to perform renal ablation in a dedicated setting, with both US and CT available, in order to merge the benefit of both techniques to improve the clinical results. The relevance of application of multiple imaging techniques to image-guided thermal ablation is underlined by the flourishing of experiences and papers on fusion imaging applied to thermal ablations in recent years [18,[26][27][28][29]. Use of both US and CT during the ablative procedure, might also increase the ability to immediately detect a vital unablated residual tissue, and thus to guide an immediate intraprocedural second ablation. ...
Image-guided thermal ablations are increasingly applied in the treatment of renal cancers, under the guidance of ultrasound (US) or computed tomography (CT). Sometimes, multiple ablations are needed. The aim of the present study was to evaluate the long-term results in patients with renal mass treated with radiofrequency ablation (RFA) with both US and CT, with a focus on the multiple ablations rate. 149 patients (median age 67 years) underwent RFA from January 2008 to June 2015. Median tumor diameter was 25 mm (IQR 17–32 mm). Median follow-up was 54 months (IQR 44–68). 27 (18.1%) patients received multiple successful ablations, due to incomplete ablation (10 patients), local tumor progression (8 patients), distant tumor progression (4 patients) or multiple tumor foci (5 patients), with a primary and secondary technical efficacy of 100%. Complications occurred in 13 (8.7%) patients (6 grade A, 5 grade C, 2 grade D). 24 patients died during follow-up, all for causes unrelated to renal cancer. In conclusion, thermal ablations with the guidance of US and CT are safe and effective in the treatment of renal tumors in the long-term period, with a low rate of patients requiring multiple treatments over the course of their disease
... Image fusion can be particularly useful also for diagnostic and therapeutic interventional procedures of small and/or inconspicuously visible renal masses (10). New and recent fields of application of fusion imaging technology are pancreatic interventions, like drainage placement guidance after pancreatitis abscessualization (11), and the assistance of endovascular treatments and follow-up (12). ...
... At the same time, kidney cancer ablation in patient with renal insufficiency assisted with EM tracking and multimodality FI with realtime CEUS and preacquired unenhanced CT and MRI without the use of iodinated or gadolinium contrasts can minimize the risks of renal damage (from iodine) and nephrogenic systemic fibrosis (from gadolinium). 37 It is relevant to bear in mind that the conspicuity evaluation of liver, kidney, or pancreatic lesions at US is operator dependent and mainly evaluated in single-institution series, sometimes but not always classified with grading scale, making interpretation of the data difficult and generalization of the findings limited. However, as for tumor ablation planning, FI appears to significantly improve the detection rate of HCC nodules, especially the small ones and when CEUS is adopted. ...
Image-guided thermal ablations are having an increasingly widespread effect on the treatment of several different abdominal conditions, and particularly on the treatment of liver and kidney tumors. In other conditions, such as in the case of pancreatic cancers, image-guided thermal ablations are still under investigation, but some studies showed promising results. Regardless the target organ to be treated, imaging represents one of the most important aspects for a safe and effective application of these techniques. To improve the image guidance in thermal ablations, some systems have been developed to fuse together two or more imaging modalities, providing the operator a real-time visualization of different information during the treatment. In the present review, the principles of fusion imaging will be described, and the principal application in the abdomen will be illustrated.
... At the same time, however, one must be aware that the risk of post-embolization syndrome and non-target embolization increases when the smallest microspheres are used. Preinterventional diagnostic MRI data can be used to simulate the tumor within the real-time images obtained during TA [82]. Currently, reliable registration and fusion of image data from different sources is a major limitation. ...
Percutaneous radiofrequency ablation (RFA) for the treatment of stage I renal cell carcinoma has recently gained significant attention as the now available long-term and controlled data demonstrate that RFA can result in disease-free and cancer-specific survival comparable with partial and/or radical nephrectomy. In the non-controlled single center trials, however, the rates of treatment failure vary. Operator experience and ablation technique may explain some of the different outcomes. In the controlled trials, a major limitation is the lack of adequate randomization. In case reports, original series and overview articles, transarterial embolization (TAE) before percutaneous RFA was promising to increase tumor control and to reduce complications. The purpose of this study was to systematically review the literature on TAE as add-on to percutaneous RFA for renal tumors. Specific data regarding technique, tumor and patient characteristics as well as technical, clinical and oncologic outcomes have been analyzed. Additionally, an overview of state-of-the-art embolization materials and the radiological perspective of advanced image-guided tumor ablation (TA) will be discussed. In conclusion, TAE as add-on to percutaneous RFA is feasible, safe and very effective for the treatment of T1a tumors in difficult locations and T1b tumors. Advanced radiological techniques and technologies such as microwave ablation, innovative embolization materials and software-based solutions are now available, or will be available in the near future, to reduce the limitations of bland RFA. Clinical implementation is extremely important for performing image-guided TA as a highly standardized effective procedure even in the most challenging cases of localized renal tumors.
... Ein weiterer Anwendungsbereich für den Ultraschall ist die Fusionsbildgebung. Der Vorteil der Bildfusion aus Ultraschall und einer Schnittbildgebungstechnik (CT, MRT) besteht darin, bei komplexen oder unklaren Befunde in der CT oder der MRT synergistisch alle Vorteile der einzelnen Modalitäten zu kombinieren [8,9]. Der Ultraschall kann in Echtzeit kostengünstig Informationen zur Perfusion ohne Applikation von Röntgenstrahlen liefern, die MRT hingegen detektiert in der Sonographie und CT übersehene kleine Weichgewebstumoren besser [8]. ...
... Der Vorteil der Bildfusion aus Ultraschall und einer Schnittbildgebungstechnik (CT, MRT) besteht darin, bei komplexen oder unklaren Befunde in der CT oder der MRT synergistisch alle Vorteile der einzelnen Modalitäten zu kombinieren [8,9]. Der Ultraschall kann in Echtzeit kostengünstig Informationen zur Perfusion ohne Applikation von Röntgenstrahlen liefern, die MRT hingegen detektiert in der Sonographie und CT übersehene kleine Weichgewebstumoren besser [8]. Helck konnte zeigen, dass die Fusion aus CEUS und CT/MRT die akkurateste Detektion eines NCC und komplexer Zysten im Vergleich zur CT/MRT und zur Sonographie allein bietet [9]. ...
... Des Weiteren werden kleine, in der CT fraglich suspekte Läsionen mittels MRT genauer charakterisiert [8]. Die funktionelle MRT-Bildgebung (Diffusion, Perfusion) ist ein weiterer Vorteil gegenüber der CT; mit ihrer Hilfe kann neben der Vaskularisation die Diffusionsrestriktion der Läsion bestimmt werden [5,29]. ...
This article elucidates the various tools used for the diagnostics and characterization of renal lesions. The advantages and limitations of ultrasound, contrast-enhanced ultrasound (CEUS), computed tomography (CT) and magnetic resonance imaging (MRI) are presented and discussed. In addition, modern imaging features of CT and MRI, such as iodine quantification in CT as well as diffusion-weighted and perfusion imaging in MRI are presented. Lastly, recent developments in standardized reporting of renal tumors regarding the intraoperative surgical risk are presented.
... Image fusion is not a new concept and is currently used in clinical practice; for example, PET and CT are often fused for diagnostic purposes to functionally and anatomically identify pathological lesions. From an interventional standpoint, modalities such as fluoroscopy and US are often advocated for image guidance [6,7]; however, in some cases, these modalities are unable to clearly visualize the target lesion. In these circumstances, fusion with modalities that have superior spatial resolution, such as CT and MRI, will enable optimal targeting whilst minimizing the disadvantages associated with performing interventions solely reliant on either modality (i.e., CT [high radiation dose] and MRI [technically more cumbersome to perform]). ...
Lesions only visible on magnetic resonance (MR) imaging cannot easily be targeted for image-guided biopsy using ultrasound or X-rays but instead require MR guidance with MR-compatible needles and long procedure times (acquisition of multiple MR sequences). We developed an alternative method for performing these difficult biopsies in a standard interventional suite, by fusing MR with cone-beam CT images. The MR cone-beam CT fusion image is then used as an overlay to guide a biopsy needle to the target area under live fluoroscopic guidance. Advantages of this technique include (i) the ability for it to be performed in a conventional interventional suite, (ii) three-dimensional planning of the needle trajectory using cross-sectional imaging, (iii) real-time fluoroscopic guidance for needle trajectory correction and (iv) targeting within heterogeneous lesions based on MR signal characteristics to maximize the potential biopsy yield.
... Somit könnte die TF diesbezüglich in manchen Fällen alternativ zur computertomografiegesteuerten Ablation eingesetzt werden [24,25]. Im Gegensatz zur Leber gibt es kaum Literatur über fusionsgesteuerte Interventionen an der Niere, obwohl Studiengruppen um Ukimura und Amalou zeigten, dass auch dies technisch durchführbar ist [26,27]. Limitationen ! ...
Technical fusion is defined as the ultrasound-guided navigation through a previously generated 3 D imaging dataset such as a computed tomography (CT) or magnetic resonance imaging (MRI). This technique allows for moving the fused CT/MRI datasets synchroneously with the real-time ultrasound in the same plane. Established and furthermore not yet described applications, the technical principles and the limitations of this promising technique will be introduced. Key points: • improves detection rates of lesions on ultrasound• more reliable size controls at different time points• may be an alternative to in bore biopsies• can be used for focal therapy Citation Format: • Aigner F, De Zordo T, Pallwein-Prettner L et al. Einsatzmöglichkeiten der technischen Fusion in der Uroradiologie. Fortschr Röntgenstr 2015; DOI: 10.1055/s-0034-1385832.
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