ECIO - European Conference on Interventional Oncology

We really enjoyed the opportunity to share some of our Interventional Oncology cases and research this week. Many thanks from the SVHG Interventional Radiology Department.

(Left to right) Dr. Colin O’Rourke, Prof. Colin Cantwell, Dr. Jeff McCann, Dr. Gerard Healy, Prof. David Brophy, Dr. Ronan Ryan

Before we sign off for the week, we would like to share some images of the beautiful Irish Countryside ☘️

Courtesy of Dr. J McCann

73-year-old female - pre-operative imaging FIGO 1b endometriod adenocarcinoma. Underwent laparoscopic hysterectomy and bilateral sentinel iliac node resection - pathological stage pT2 N1 R0.
Fig 1 – pre-operative pelvic MRI

Developed post-operative chylous ascites, which were unresponsive to conservative management with repeated percutaneous drainage and TPN for several weeks.
Fig 2 – Post-operative CT demonstrating ascites

IR consulted in the MDT setting for assistance with management. The consensus decision was to proceed with lymphangiography with a view to embolisation, if a lymphatic was demonstrated. Under conscious sedation and US guidance bilateral inguinal node puncture was performed using 25G needles. Lymphangiography was performed with slow injection of Lipiodol and with intermittent fluoroscopy.

Fig 3 – Lymphangiographic images. (a) (b) demonstrate abnormal extra-lymphatic Lipiodol accumulation in the right hemipelvis and deeper in the pelvis (arrows).

Video 1 - Cone beam CT images were acquired and the location of the leak was demonstrated.

Fig 4 – Cone beam CT images showing Lipiodol accumulation within pelvic ascites and localising the lymphatic leak (arrows).

Video 2 - Percutaneous puncture of the right pelvic lymphatics under fluoroscopic guidance using an angled 21G needle. Embolisation of the lymphatic leak was then performed using a 1:1 mixture of Glubran and Lipiodol.

Fig 5 – angled 21G needle puncture of right iliac lymphatics at the site of leakage.

TPN discontinued immediately post embolisation and oral diet was recommended. A displaced ascetic drain was also removed. Abdominal swelling and bloating quickly resolved after lymphatic embolisation and there was also clinical and radiological resolution of ascites.

Fig 6 – CT images from day 1 post lymphatic embolisation demonstrate small volume ascites with some retained intraperitoneal Lipiodol in the pelvis.

The patient was discharged home 2 days following lymphatic embolisation. She experienced some mild bilateral calf swelling which subsequently improved at a later follow up.

Fig 7 – Two-week CT follow up demonstrated progressive ascites resorption with denser concentrated pooling of Lipiodol in the pelvis.

Today is clinic day for some of our IRs. We have had an established fibroid embolization clinic in place for 15 years, where all patients are seen pre-procedure along with six weeks and six months post procedure.

We have used this infrastructure to establish pre and post consultations for our interventional oncology patients in recent years. This has become more formalised after recent IASIOS accreditation.

Our clinical nurse specialist in interventional oncology, clinical specialist radiographer and entire team are very involved in the workup and coordination of these cases.

The_IASIOS

Research led by Dr. Gerard Healy

We recently published our experience of image guided ablation for HCC at the Irish Liver Transplant Centre - St Vincent's University Hospital. Read it in the Canadian Association of Radiologists Journal: https://pubmed.ncbi.nlm.nih.gov/39344072/

177 thermal ablations in 118 patients. Mean follow-up 21 months. 84.8% (n = 95) long term local complete response to therapy. No survival difference between MWA vs RFA and no diff >/< 3cm size. Complications in 5.9% (n = 10) but 90% minor.

Fantastic work by SVUH radiology specialist registrars Dr. Syer Ree Tee and Dr Hannah Hughes. Cases performed by Prof Colin Cantwell, Dr Jeff McCann, Dr. Ronan Ryan, Dr. Colin O’Rourke, Dr. Gerard Healy

Figure 1: Sagittal reconstruction of CT liver, arterial phase. LIRADS 5 HCC in liver segment 2.
Figure 2: Needle placement into the lesion using Imactis® CT-Navigation at time of percutaneous ablation. Case performed by Dr. Colin O’Rourke

Case by Dr Gerard Healy
This lady presented to our hospital with jaundice and weight loss. MRI showed a 2cm central liver mass with adjacent right intrahepatic biliary obstruction (Fig 1, arrow. Also focal fat segment 4).

There were background changes of cholangiopathy, consistent with new diagnosis of primary sclerosing cholangitis. A percutaneous transhepatic cholangiogram confirmed cholangiopathy with central right hepatic duct stricture (Fig 2, see arrow), corresponding to the site of the mass on MRI.

Fluoroscopic biopsy of the stricture was negative on two occasions. Our dept has recently introduced percutaneous biliary endoscopy. Decision for endoscopic biopsy of the stricture. Figure 3 shows relatively normal common duct, with Amplatz wire in situ. Figure 4 shows the central right intrahepatic duct stricture with friable mucosa. Multiple biopsies were taken under direct visualisation (Figure 5), confirming diagnosis of intrahepatic cholangiocarcinoma. Considered anatomically unresectable. The patient started chemoradiotherapy.

Fig 1: T1 axial MRI with contrast showing central right hepatic mass (arrows) with right posterior biliary dilation
Fig 2: PTC showing diffuse cholangiopathy and central right intrahepatic duct stricture (arrow)
Fig 3: Common duct with Amplatz wire in situ
Fig 4: Central right intrahepatic bile duct stricture
Fig 5: Biopsy of the abnormal bile duct mucosa at site of the stricture

Research by Prof. Colin Cantwell Quality assuring IR for 30 years! Finding a complication rate can be difficult… CVIR - CardioVascular and Interventional Radiology recently published our searchable index of rates for QA in IR
➡️ https://link.springer.com/article/10.1007/s00270-024-03859-x

Strong work from medical student and future IR, Aren B. Mnatzakanian
➡️ http://bit.ly/3BtUVvr

Case by Dr. Colin O'Rourke

64-year-old female, ALD cirrhosis with 6.7 cm Segment VI HCC. We performed a radiation segmentectomy via radial access with 400 Gy dose to the perfused volume. The patient had her follow-up scans this morning and we are pleased to see ongoing complete treatment response two years post radioembolization.

Fig 1: Pre-treatment Axial CT demonstrating washout of the Segment VI lesion.
Fig 2: Cone beam CT showing arterial enhancing 6.7 cm mass.
Fig 3: PET CT post administration of TheraSphere y90.
Fig 4: Post-treatment Axial CT two years post-treatment showing non-enhancing lesion, now measuring 1.6 cm.

We are excited to introduce this week's by Prof. David Brophy and the team at the St. Vincent's Healthcare Group in Ireland!

"Hello CIRSE/ECIO community,
St. Vincent's Healthcare Group (SVHG) is situated in Dublin, Ireland and includes St. Vincent's University Hospital, St. Vincent's Private Hospital, and St. Michael's Hospital.

There are 6 interventional radiologists working with a team that includes 18 nurses and over 100 radiographers.

In 2023, approximately 250,000 radiology examinations and procedures were performed in the SVHG group, which includes approximately 15,000 image-guided procedures performed over 4 interventional radiology suites.

SVHG is a tertiary and quaternary referral centre, including the National Surgical Centre for pancreatic disease, neuroendocrine disease, sarcoma, cystic fibrosis and the National Liver and Pancreative Transplant Hospital. We are also a tertiary referral centre for vascular disease and a major tertiary oncology referral centre.

We look forward to sharing some of our cases with you over the coming few days."

Abstract submission for is now open! Submit your abstract by January 9 to share your work at the world's biggest interventional oncology platform!

Accepted abstract types include:
➡️ Scientific abstracts
➡️ FIRST@ECIO clinical trial abstracts
➡️ Educational abstracts
➡️ Case reports

Learn more and submit here: https://t.ly/5eHX_

In recognition of Liver Cancer Awareness Month this October, the CIRSE Library is providing free access to lectures on liver cancer from the 2024 IO Foundation Course and . These lectures offer a comprehensive overview of interventional oncology procedures for liver cancer and highlight their role within a multidisciplinary approach to cancer care. ➡️ library.cirse.org/

To watch, simply log in with your myCIRSE account.
Make sure to share these lectures with your colleagues!

In honour of Breast Cancer Awareness Month in October, check out this session from in the CIRSE Library to highlight interventional oncology's role in treating this disease:

"Breast cancer: new scenarios for an old disease"
➡️ https://t.ly/AllCM

with Prof. Reto Bale
featured on Austrian TV. Raising awareness of the treatments we offer is key for the future of interventional radiology.

Innsbrucker Arzt verbrennt Tumore Wenn jemand einen ganz eigenen Weg einschlägt, wird er oft als verrückt oder als Genie angesehen. Reto Bale, ein Radiologe aus Innsbruck, ist als der „Crazy Austrian“ auf Ärztekongressen bekannt. Er behandelt bösartige Tumore in der Leber mit innovativen Methoden, die über die gängigen The...

with Prof Reto Bale
It was a pleasure sharing the work my team and I do with you this week. To learn more, join us in Innsbruck this December for the ESIR course on percutaneous tumour ablation!
👉 https://t.ly/VbU7A
It will be a fantastic opportunity to gain hands-on experience with cutting-edge technology under the guidance of top experts in the field. You will also have the chance to explore the capabilities of modern 3D guidance devices and image fusion tools, along with a recorded case of stereotactic radiofrequency ablation and other interesting cases for group discussion.

with Prof. Reto Bale

A case from a colleague, Dr. Moritz Kummann.

This 63-year-old patient had been treated with atypical resection of a singular colorectal liver metastasis in segment VIII in 2019. Local recurrences were treated with resection (09/2021), MWA (02/2022) and sRFA (07/2022).
In July 2024 the patient was presented to our institution with a large local recurrence of 5.5 x 2.5 cm medial to the ablation zone in segment IVa in close vicinity to the vena cava and the hepatic veins. Stereotactic radiofrequency ablation was performed, using 4 needles with needle retraction and 2 ablation zones per needle. Total ablation time was 31 minutes. 2500 units of heparin were administered to prevent occlusion of the hepatic veins.

with Prof. Reto Bale

This is one of our SRFA cases from yesterday with a patient who acquired two new hepatocellular carcinomas (Segment IVa/VIII measuring 3.1 cm and Segment II/III measuring 4.3 cm) following liver transplantation. Click here to view the full case, videos will play when you click on their images:https://www.cirse.org/wp-content/uploads/2024/10/case-BR-for-friday-youtube.pdf

with Prof. Reto Bale
What are the links between SIPLab Innsbruck, the Hollywood Boulevard, and “Breaking Bad”?
Patient immobilization is essential for stereotactic /robot-assisted punctures. This was significant for early 3D-navigated endonasal ENT surgeries, as the 3D navigation system (ISG Viewing Wand) was self-referential. Consequently, in collaboration with my fellow student and friend Michael Vogele, we developed and evaluated multiple non-invasive head fixation devices. The initial attempts utilizing my motor helmet alongside a custom nose mold were ineffective.
Figure 1: Preliminary design of a stiff fixation apparatus: a) Reto Bale`s motor helmet, b) “nose mold” from Michael Vogele.
Read on in the comments!

with Prof. Reto Bale
During this takeover, I would like to introduce our section, “Interventional Oncology – Stereotaxy and Robotics (SIP)”.

First, let's take a brief look back at an incredible 30-year journey:
Exactly 30 years ago, in the autumn of 1994, the first commercially available frameless stereotactic navigation system, the ISG Viewing Wand (Figure 1), was delivered to the ENT Clinic in Innsbruck. This 3D navigation system was developed to assist the surgeon with intraoperative orientation and to protect important anatomical structures (nerves, vessels). This is particularly helpful when anatomical landmarks are not visible due to tumors or bleeding. As a medical student, I had the opportunity to observe the first 3D-navigated endonasal ENT procedures in Europe conducted by Prof. Walter Thumfart and Prof. Andreas Gunkel. Later, I had the chance to assist alongside the medical physicist Prof. Wolfgang Freysinger and my fellow student, Michael Vogele.

During an accuracy study on a temporal bone in the ENT operating room, I had the idea for a device or needle guide that allows for precise targeting of any point from the outside using the 3D navigation system, just before midnight. Together with Michael Vogele, we subsequently created several prototypes, filed the corresponding patents, and licensed them to large medical technology companies, including Medtronic (Vertek TM) and Philips (EasytaxisTM) (Figure 2). These new targeting devices opened up completely new possibilities and revolutionized neurosurgery, followed by other disciplines.

Until this point, precise neurosurgical punctures were only possible through stereotactic frames, which had to be secured to the skull cap with screws. With our new devices, which are still in use today (albeit in modified form), we were able to perform precise punctures in the head area for the first time without an invasive frame.

To prove the accuracy of the new method, we first punctured the foramen ovale in cadavers and then, in 1996, performed the world's first frameless stereotactic thermocoagulation of the Gasserian ganglion for trigeminal neuralgia (together with Eugen Ladner, MD and Arno Martin) (Figure 3).

Subsequently, we used our new targeting devices for numerous 3D-navigated punctures in the head area: brachytherapy for ENT tumors (together with Prof. Peter Lukas, radiation therapy, and team) (Figure 4), brain tumor biopsy (together with Prof. Wilhelm Eisner), placement of foramen ovale electrodes in epilepsy patients (together with Prof. Martin Ortler), endoscopic ventriculocystostomy (together with Prof. Johannes Burtscher).

To apply this technology and workflow for targeted, minimally invasive tumor and pain therapy "from head to toe," we founded the SIP Lab (SIP: Stereotaxy, Intervention, and Planning) in 1996 at the Radiology Department (together with the former chairman Prof. Werner Jaschke). With the 3D navigation system (StealthstationTM, Medtronic), our aiming devices, and patient fixation systems, we (together with Dr. Peter Kovacs, RT Thomas Lang, RT Martin Knoflach) (Figure 5) supported various frameless stereotactic procedures across different departments (orthopedics, trauma surgery, maxillofacial surgery, neurology).

However, the main focus of our team was on the development of new or improved minimally invasive percutaneous interventional radiological procedures for tumor and pain therapy. These will be exemplified in the upcoming posts.

Our core medical team currently consists of 7 radiologists (Reto Bale, Peter Schullian, Daniel Putzer, Gernot Eberle, Moritz Kummann, Gregor Laimer, Yannick Scharll) and ten specially trained radiologic technologists (Figure 6, From left to right: Florian Schanda, Reto Bale, Verena Götzl, Gernot Eberle, Moritz Kummann, Julia Mahlknecht, Gregor Laimer, Josef Walch, Daniel Putzer, Anna-Verena Gschwentner, Yannick Scharll, Peter Schullian.Not depicted: Roland Mahlknecht, Hannah Haidacher, Johanna Partl, Martina Weiler, Moritz Schuhmacher).

Additionally, two PhD students (Stefano Fogarollo, Adela Lukes) are working on optimizing image fusion and automatic path planning for stereotactic radiofrequency ablation (SRFA) as part of an FWF project (DocFunds).