Jpn J Intervent Radiol Vol.23 No.3 2008

State of the Art
Percutaneous Cryoablation : Basis, Clinical Application and Future

1. Death of Cell and Tissue in Cryosurgery

Dr. Sajio Sumida Clinic
Sajio Sumida

This paper describes the three mechanisms of cryo-destruction of cells and tissues (referred to as the ‘target’) in cryosurgery. These mechanisms include 1) mechanical and osmotic destruction of the target cells, 2) cryo-necrosis due to microcirculatory failure combined with inflammation and 3) cryo-immune responses.
There are a host of variables that are involved in the causes of cryo-destruction of the target. They include: sizes of cryoprobes, the kinds of refrigerant, the method of generation of low temperature, the cooling and warming rate, the general condition of patients, the location and size of target, and the strength of immune responses. The author describes these mechanisms conceptually because it is so difficult to strictly designate any one individual variable.
Cryosurgery takes a relatively longer time for complete wound-healing of the cryo-destructed target in contrast to surgical ablation intervention of the target by conventional resection. However, the author emphasizes that cryosurgery has some unique advantages that cannot be left unmentioned, namely, it is the treatment of choice for unresectable tumors located on the face, vulva, and porta hepatis.

Key words

  • Cryoinjury
  • Cryomicroscope
  • Cell death at low temperature
  • Intracellular ice formation


2. Image-Guided Cryoablation

Department of Biomedical Science and Engineering, Faculty of Health Sciences, Hokkaido University
Tadashi Shimizu

Image-guided thermal ablation has become a popular category of interventional radiology. Radiofrequency ablation, laser interstitial thermal ablation, high-intensity focused ultrasound, microwave coagulation and cryoablation are included in this category. An image-guided technique for cryoablation was developed at the end of this last century. We are able to choose ultrasonography (US), computed tomography (CT) or magnetic resonance imaging (MRI) for targeting tumors and monitoring the freezing process. Each imaging modality has its own characteristics. US is widely employed for targeting many kinds of lesion because of its high temporal resolution. However, only the near surface of the iceball is delineated on the ultrasonogram. CT-guidance is available for targeting and monitoring cryoablation of lung and bone tumors. The ablation zone is of high density in the lung. On the other hand, the frozen area is visible as a low density area in other organs. MR imaging provides a very high contrast between frozen and non-frozen tissue, and multiple slice and multidirectional images are useful for observing the shape of the frozen area and its spatial relation to adjacent tissue. Real time thermal mapping of the frozen tissue and tumor visualization in the ablation zone are necessary for safer and more accurate cryoablation.

Key words

  • Image-guidance
  • Cryoablation


3. Cryosurgery for Breast Disease

Kameda Medical Center, Breast Center
Eisuke Fukuma, Shinji Ozaki, Mitsuhiro Tozaki, Naomi Sakamoto
Satoko Abe, Terumasa Kurihara, Takako Suzuki, Michiko Sagawa

Since 2006 we have applied cryosurgery for various breast diseases including small breast cancer, fibroadenoma, and advanced breast cancer to enhance immunity.
Eight patients with small breast cancer (mean size 7.6㎜) had non-surgical cryoablation, and a short follow up failed to reveal any local recurrence at the ablated sites. Four patients had cryoablation for fibroadenoma and have never experienced recurrent tumor. Although cryosurgery for breast disease has potential for development, we have to accumulate further cases and evaluate pathological lesions taken from post-ablated lesions.

Key words

  • Cryosurgery
  • Small breast cancer
  • Fibroadenoma
  • Cryo-assisted lumpectomy


4. Percutaneous Cryoablation for Pulmonary Malignancies

Department of Diagnostic Radiology and Department of Thoracic Surgery1), School of Medicine, Keio University
Seishi Nakatsuka, Hideki Yashiro, Masanori Inoue
Masafumi Kawamura1), Yotaro Izumi1), Sachio Kuribayashi

Our experience of percutaneous cryoablation for pulmonary malignancies (PCP) under CT fluoroscopic guidance and the difference from RF ablation will be mentioned.
All procedures were percutaneously performed under local anesthesia with a multi-detector row CT scanner using multi-slice CT fluoroscopy. A coaxial technique using a 21-gauge fine needle and an 8 to 11-gauge coaxial needle was applied to penetrate a tumor. Tumors were frozen into iceballs using high-pressure argon and Joule-Thomson effect.
More than 100 patients with more than 200 primary or secondary pulmonary malignant tumors underwent percutaneous cryoablation. The procedure was well tolerated by all patients. One- and two-year local control rates were about 80% and 70%, respectively. Complications included pneumothorax, pleural effusion and hemothorax. The rate of chest tube insertion stayed around 10%.
The biggest difference from RFA is painlessness in PCP sessions. In addition, multiple cryoprobe activation is possible in PCP and the difficulty of the PCP procedure should be mentioned. Our experience confirms the feasibility, safety and efficacy of PCP.

Key words

  • Cryoablation
  • Lung cancer
  • Metastatic lung tumor
  • CT fluoroscopy


5. Intratumoral Administration of BCG-CWS Treated DC Following Tumor Cryoablation

Division of Cellular Signaling, Institute for Advanced Medical Research, Keio University School of Medicine
Yutaka Kawakami

Based on the analysis of immune responses to human cancer, we have developed immuno-therapy combined with tumor cryoablation. In murine bilateral tumor models, intratumoral administration of BCG-CWS treated dendritic cells following tumor cryoablation resulted in inhibition of remote untreated large tumors. The enhanced uptake of tumor antigens by the injected DC through tumor cell necrosis and apoptosis induced by cryoablation, and the DC stimulation with TLR stimulating BCG-CWS, enhanced induction of anti-tumor CD8+ CTL through efficient antigen spreading, and induced tumor regression. Based on the mouse study, clinical trials of this protocol were performed for patients with melanoma, primary lung cancer, and liver metastasis of colon cancers. In some patients, SD with decreased tumor markers was obtained along with induction of systemic immune responses. Improved protocols are currently designed for more effective immunotherapy with cryoablative tumor treatment.

Key words

  • Cryoablation
  • Immunotherapy
  • Dendritic cells

Case Report
A Successful BRTO for the Gastric Varices with Double Balloon Obliteration

Department of Radiology, Kitasato University East Hospital
Saori Kawamura
Department of Radiology, National Hospital Organization Sagamihara Hospital
Masakazu Takigawa
Department of Radiology, Jisei-kai Daini Hospital
Mayumi Sasaki
Gastroenterology Division of Internal medicine, Kitasato University East Hospital
Hisashi Hidaka
Department of Radiology, National Hospital Organization Tokyo Medical Center
Yoshinori Isobe

A man in his 60’s with grade C liver cirrhosis was prophylactically treated for enlarged fundal gastric varices by balloon-occluded retrograde transvenous obliteration(BRTO). Contrast-enhanced CT revealed large fundal varices with the posterior gastric vein as an afferent vein and the left adrenal vein as a draining vein. The main gastrorenal shunt could not be completely blocked with a 6-Fr balloon catheter because of another small shunt that branched from the large gastrorenal shunt and rejoined the larger shunt before draining into the left renal vein (ring-type gastrorenal shunt). A 5-Fr balloon was inserted from the right internal jugular vein into the small gastrorenal shunt. Then, a 6.5-Fr balloon was introduced from the right femoral vein and positioned in the large gastrorenal shunt. Inflation of the two balloons resulted in occlusion of both the gastrorenal shunts. One-week after the treatment, follow-up CT scans revealed thrombosed gastric varices. Simultaneous blocking of the branched gastorenal shunt occluded successfully the blood flow into the left renal vein, resulting in complete sclerosis of the large fundal gastric varices.

Key words

  • Gastric varices
  • Balloon-occluded retrograde transvenous obliteration (BRTO)
  • Evacuation


Case Report
Idiopathic Renal Arteriovenous Fistula Successfully Treated by Transvenous Coil Embolization

Department of Radiology and Urology1), Kumamoto Red Cross Hospital
Shinichi Nakamura, Takeshi Sugahara, Koya Nakashima, Hideyuki Fukui1),Kanako Ito, Yuji Baba, Kazuyoshi Ikeda1), Tomoko Kuwata1)

A man in his forties was referred to our hospital because of suspicion of a right renal aneurysm on ultra-sonography(US). MR angiography performed in our hospital revealed an idiopathic arteriovenous fistula (AVF) in the right kidney.
Although the patient was asymptomatic, there were concerns about the complications such as cardiomegaly or high-output cardiac heart failure in the future, and coil embolization was initiated. First, a microcatheter was inserted in the renal artery, but failed to reach the AVF. Second, the microcatheter was advanced by way of the renal vein and easily placed into the AVF. Subsequently, coil embolization using IDC was performed under arterial flow control with balloon catheter, with the AVF completely disappearing.
Transvenous embolization should be considered as one interventional treatment of idiopathic renal AVF.

Key words

  • Arteriovenous fistula
  • Embolization
  • Occlusion coil

Special Commentary
The steps of Interventional Radiology -Forward and Behind-

Prof. Emeritus, College of Medical Technology, University of Hokkaido
Office-IVR . Hokkaido
Yutaka Morita

The developmental history of vascular interventional radiology (Vascular-IVR) outlined focusing on the following 5 points : 1) The history of angiography. 2) Intra-arterial infusion chemotherapy. 3) Embolization and embolic materials. 4) Percutaneous transluminal angioplasty (PTA) and the stent, the stentgraft. 5)IVR in Japan.
In addition, achievements and anecdotes of the pioneers and inventors are introduced in the following 5 stories.
1) Cerebral angiography of Egas Moniz and thorotrast. 2) Seldinger, SI and his method. 3) Gianturco, C and wooly tails. 4) Five great achievements of Charles T, Dotter. 5) Gruntzig dilating balloon and percutaneous coronary angioplasty (PTCA).
Taking a general survey of these pioneers’ achievements, it can be seen that one development accelerate the progress of other improvements, and key points of development are to make a ceaseless effort.