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Biopsy, Needle Localization, and Radiofrequency

Ablation for Pediatric Patients

Fredric A. Hoffer, MD FAAP, FSIR

histochemical staining can be obtained from specimens pre-

Pediatric interventions for oncology patients include aspiration or
percutaneous biopsy for malignancy diagnosis or recurrence,
served in 10% formalin.
and percutaneous biopsy for the complications of tumor treat- Obtaining genetic information is often necessary to differen-
ment. Tumor localization techniques have been used to resect tiate these small blue round-cell tumors. Genetic testing re-
small lesions with minimal invasion. However improved guidance quires at least two passes with a 15-G needle and the placement
techniques have allowed for more precise biopsy and the use of of the fresh material in RPMI 1640 (Roswell Park Medical
thermal ablation instead of excision for local tumor control. I will Center) transport media. In the past, I relied on culturing the
discuss these diagnostic and therapeutic techniques as they tumor for cytogenetic analysis.1,2 At St. Jude and other major
apply to children. oncology centers, a solid tumor panel of genetic translocations
© 2003 Elsevier Inc. All rights reserved. (t) can be screened with a polymerase chain reaction (PCR)
technique (in the department of molecular pathology). The
solid tumor PCR panel includes at least Ewing sarcoma family
Atraumatic Care
of tumors [t(11;22)(21;22)], alveolar rhabdomyosarcoma [t(2;
Atraumatic care is important when dealing with pediatric on- 13)], and synovial sarcoma [t(X;18)].
cology patients. When children face a chronic disease, any Fresh tissue placed in RPMI 1640 is also used for FISH
painful experience will sour their outlook and heighten there (fluorescent in situ hybridization) techniques. The FISH tech-
aversion to pain. It is important to place topical anesthetic nique obtains the genetic information necessary to establish
preparations such as lidocaine/prilocaine or 4% lidocaine on prognosis for neuroblastoma including MYCN gene amplifica-
the skin for 60 to 45 minutes, respectively, with an occlusive tion and loss of the short arm of the first chromosome (1p⫺),
dressing before obtaining percutaneous or IV access. Prilocaine which are poor prognostic indicators. FISH for 1p⫺ can also be
cannot be used in the newborn due to the risk of methemoglo- obtained in Wilms’ tumor to assign risk-based treatment. The
binemia. I prefer to have an anesthesiologist in attendance for DNA index (ploidy) of the primary tumor is also necessary for
all biopsies and ablations. the treatment of neuroblastoma and can be obtained from two
passes of a 15-G core biopsy needle.3 Low DNA index (diploid)
of the primary neuroblastoma in the first 2 years of life corre-
Percutaneous Tumor Biopsy lates with a poor prognosis.
As a pediatric radiologist I perform more biopsies than any The Children’s Oncology Group, the one remaining cooper-
single surgeon in our institution. This reliance on percutaneous ative cancer group for children in the United States, also re-
biopsy occurs in many adult hospitals but is not as widespread quires a determination of favorable or unfavorable histology for
in pediatric institutions. Building a successful biopsy practice neuroblastoma based on the Shimada pathology classification
involves carefully planning how the material is obtained and system.4 This requires examining the excised specimen grossly
processed. Adult carcinomas often can be diagnosed by cytol- to determine tissue nodularity and microscopically to count
ogy alone. Pediatric tumors, which are often lymphoma, sar- 1000 cells. I have shown that imaging and percutaneous needle
coma, and blastoma, often appear as small round blue cells and sampling of the primary tumor is sufficient to assign favorable
need core biopsy tissue for further analysis. Obtaining core or unfavorable histology for neuroblastoma.3 Unfortunately,
biopsies with a 15-G spring-loaded core biopsy needle helps the percutaneous biopsy material is not currently accepted for in-
pathologist have adequate tissue for histopathology, immuno- clusion in a COG neuroblastoma protocol.
pathology, molecular pathology, and cytogenetics. Immuno- Recently, I have studied percutaneous biopsy and aspiration
material obtained for the diagnosis and recurrence of lym-
phoma and leukemia.5 Percutaneous biopsy of lymphoma in-
From the Division of Diagnostic Imaging, Department of Radiological cluding Hodgkin’s disease is usually diagnostic. Drainage or
Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, aspiration of a fluid collection associated with non-Hodgkin’s
USA. lymphoma or leukemia is often diagnostic and is less invasive
Supported in part by Cancer Center Support (CORE) Grant CA 21765
from the National Cancer Institute and by the American Lebanese Syrian
than biopsy. To diagnose Hodgkin’s disease, one has to be lucky
Associated Charities (ALSAC). enough to find a Reed Sternberg cell. The other hematologic
Address reprint requests to Fredric A. Hoffer, MD, Division of Diagnos- malignancies need to be identified by histology and immuno-
tic Imaging, Department of Radiological Sciences, St. Jude Children’s chemistry. Formalin-fixed tissue can be stained for antibodies,
Research Hospital, 332 N. Lauderdale St., Memphis, TN 38105, USA. a technique termed immunohistochemical staining. Flow cy-
Fax: 901-495-4398. E-mail: fred.hoffer@stjude.org
© 2003 Elsevier Inc. All rights reserved.
tometry can analyze antibody labeling of the tumor from fresh
1089-2516/03/0604-0007$30.00/0 tissue placed in RPMI 1640. If an aspirate of a fluid collection is
doi:10.1053/j.tvir.2003.10.003 submitted for flow cytometry, it should be heparinized. Some

192 Techniques in Vascular and Interventional Radiology, Vol 6, No 4 (December), 2003: pp 192-196
children with large mediastinal masses could obstruct their dice, and hepatic tenderness or enlargement. If a transjugular
airway or systemic venous return during anesthesia. If they biopsy is done, measurement of the free and wedge hepatic
have impaired peak expiratory flow or tracheal narrowing over venous pressures may document the portal hypertension that
50%,6 the least sedation possible should be used for a simple occurs with this disease. Many are performed after day ⫹21
percutaneous needle aspiration or more invasive percutaneous when engraftment of the transplanted cells occurs and the pa-
biopsy. tient becomes more jaundiced with suspected graft versus host
disease. In this setting, I obtain material for histopathology,
viral, bacterial, and fungal culture, and most recently PCR for
Lung Biopsy for Invasive Aspergillosis
specific viruses.
Invasive pulmonary aspergillosis occurs with frightening regu-
larity in our immunosuppressed patients.7 A mortality rate of
Tumor Localization
82% has been reported for recipients of bone marrow trans-
plants.8 Until now, none of our patients have survived without I have used a Kopans breast biopsy needle (Cook, Inc.) to
surgical resection. The newer antifungal agents show promise deliver 0.1 to 0.2 mL of methylene blue dye and a hooked wire10
of controlling this disease without resection. Galactomannan, a into small masses for excisional biopsy. However, I prefer to
cell-wall antigen of Aspergillus, can now be detected in the biopsy small lesions, recurrences, or metastases under real-time
peripheral circulation. Using this test and the enhanced CT CT or US guidance and then ablate them with radiofrequency
appearance may be all that is necessary to diagnose this infec- rather than have them excised by surgery. Needle localization
tion. The halo around a small nodule is an early imaging char- has been most useful when a small lung nodule is present under
acteristic of invasive aspergillosis. Central necrosis on en- the pleural surface. This will not be seen and cannot be felt
hanced CT or MR is a reliable sign in a larger nodule in a patient during thoracoscopic surgery. Needle localization has allowed
with an absolute neutrophil count (ANC) of less than 1000 less invasive thoracoscopic surgery to replace conventional
cells/ mm3. When the ANC is in the normal 1000⫹ range, a thoracotomy for excision of these lesions.
crescent of air may appear between the necrotic center and
viable rim of the pulmonary aspergillosis. Percutaneous CT-
guided biopsy of the lesion is fairly accurate7 and will select
Guidance Techniques
patients that would benefit from pulmonary resection. When If a lesion can be visualized by US, this is the preferred guidance
biopsying the lung, I often use a coaxial technique with a 19-G modality for any percutaneous procedure. The disadvantage of
sheath and a 20-G spring-loaded core biopsy needle. Material is using US with radiofrequency (RF) ablation is that the gas that
sent for KOH preparation, fungal cultures, and histopathology. forms during the ablation may obscure the far edge of the
tumor. European radiologists have the advantage of readily
accessible ultrasound contrast agents.11 US contrast agents
Liver Biopsy Techniques: Transjugular or make lesions more conspicuous, which allows more precise
Coaxial Percutaneous placement of the RF probe into the mass. More importantly,
I have performed percutaneous coaxial hepatic biopsies and when the RF ablation is thought to be completed, additional US
transjugular hepatic biopsies on pediatric oncology patients.9 contrast agent can be given. If a portion of the tumor remains
Percutaneous liver biopsies are reserved for patients that do not viable, the RF probe can be repositioned and the remaining
have an increased risk of bleeding. Transjugular liver biopsy is tissue can be ablated before the session ends.
indicated for patients with coagulopathy, thrombocytopenia, Pulmonary and osseous lesions are best approached with CT
prolonged bleeding time, ascites, or those at risk of hepatic guidance. Real-time CT (CT fluoroscopy) may generate exces-
venous hypertension: bone marrow or stem cell transplant re- sive radiation dosage to the examiner and the child unless used
cipients at risk of hepatic venoocclusive disease (HVOD) from in a spot-check manner.12 A compromise CT guidance system
day ⫺7 to day ⫹30. is a single- or multislice-image acquisition controlled by the
Percutaneous technique is always guided by color-flow radiologist in the CT scanning room. Although not a real-time
Doppler sonography (US) to avoid vessels. One gram of micro- technique, the radiologist can get spot CT images within sec-
fibrillar collagen (Avitene, MedChem Products, Inc. Woburn, onds of needle or probe manipulation and view them without
MA) is mixed with 10 mL of normal saline and drawn up into a leaving the room. If there is a small lung nodule, the young
1-mL syringe. A 17-G sheath and 18 spring-loaded biopsy nee- patient may require general anesthesia with controlled breath-
dle is used for the coaxial biopsy. The collagen mixture is then ing during biopsy or RF probe advancement. Virtual CT guid-
injected into the 17-G sheath under US guidance as the sheath ance systems (e.g., UltraGuide, Inc., Lakewood, CO and Tirat
is withdrawn. Color-flow Doppler US can then monitor bleed- Hicarmel, Israel) are also available and may aid in biopsy or RF
ing from the tract. Bleeding will have color flow and the colla- ablation of small liver nodules that are not visible on either US
gen will appear echogenic without flow. To document the or noncontrast CT. This technique allows the real-time projec-
quantity of hemosiderosis in patients who have undergone tion of a needle or probe onto the preexisting contrast-en-
chronic transfusions, two dry specimens should be sent in a hanced CT image. This technique also allows off-axial guidance
metal-free container surrounded by ice. of the needle placement. Combined CT and US guidance may
The transjugular technique starts with free-hand US guid- be necessary for some difficult biopsies or ablations.
ance to access the internal jugular vein. Then a LABS 200
system (Cook, Inc., Bloomington, IN) is used with a spring-
Radiofrequency Ablation of Osteoid Osteoma
loaded 19-G core biopsy needle through the hepatic vein. Bi-
opsy is rarely required to document HVOD disease since it is Osteoid osteoma is a common benign cortical bone lesion in
usually diagnosed clinically with a triad of weight gain, jaun- children and adults that classically gives the patient night pain


partially relieved by anti-inflammatory agents. The radiolucent mors such as hepatoblastoma and osteosarcoma are not sensi-
nidus is not usually larger than 1 cm in diameter and is best seen tive to radiotherapy and benefit from complete excision. If
on CT. The nidus produces a sclerotic reaction in the cortical surgical excision of these tumors or their metastases is not
bone as noted by radiograph or CT and inflammation in the possible, RF ablation is warranted.
medullary portion of the bone as noted by MR or scintigraphy. A pain service consultation is obtained before the procedure;
RF ablation is the treatment method of choice for osteoid os- all pediatric patients are placed under general anesthesia, and
teoma in children and adults.13 Rosenthal recently reported patient-controlled analgesia is arranged as an inpatient at least
experience in over 250 patients with primary and secondary overnight after the tumor ablation. I prefer to use the Radionics
success rates of 91 and 60%, respectively, with immediate relief Cool Tip ablation system and have found that using the triple-
of pain.13 Surgical excision of the osteoid osteoma is unneces- cluster probe is most effective. Cooling of the tip and imped-
sary and carries the risk of missing the lesion and fracturing the ance control allows larger burn areas by avoiding high temper-
bone.14 Percutaneous excision under CT guidance is an alter- atures and charring near the probe. Burn times of 12 minutes
native.15 The percutaneous excision requires a large trephine per position are required in the liver and shorter burn times are
needle driven by an electric drill. The nidus and a considerable allowed in less vascular organs such as the lung or musculo-
portion of cortex are excised. Because of the cortical bone loss skeletal system. If temperatures of 60°C are obtained, then
and the risk of fracture, the patients are kept on crutches for 6 instantaneous tissue death is assured. Temperatures over 50°C
weeks after the core excision. over several minutes will also completely ablate the tumor.
The technique for RF ablation of osteoid osteoma is well Overlapping burns should be performed so that all the tumor
developed.16,17 The patient is placed under general anesthesia and cuff of 1 cm normal tissue (which may harbor microscopic
since the biopsy or ablation of an osteoid osteoma is very pain- disease) reach these critical temperatures. When the ablation
ful. The lesion can be biopsied with a 14-G Ackerman needle cycle in each position is finished, the cooling is turned off and
under CT guidance. This allows passage of a 17-G RF probe the probe is heated to 80°C without impedance control to as-
into the center of the nidus. I recommend using a thermocouple sure that the tissue in contact with the probe is also ablated.
(TC) noncooled probe with a 5-mm active tip (Radionics, Di- This noncooling technique can also be performed as the needle
vision of Tyco Health care group LP, Burlington, MA). This is withdrawn at 1-minute intervals to burn the needle tract and
probe distributes heat over a 1-cm-diameter volume, effectively prevent tumor spread and bleeding. The probe can be touched
ablating the small nidus of the osteoid osteoma.13 The sheath to assure there is no burning of the skin as it is withdrawn.
must be pulled back so that it is over 1 cm from the active The Italian investigators have the most experience using RF
portion of the RF probe. This will avoid heating the sheath and for ablating hepatomas or hepatic metastases describing 0.3%
the soft tissue, nerves, and skin the sheath passes through or mortality and 2.2% major complication rate for liver tumor RF
near. The generator is placed on manual mode and tempera- ablation19 in adults. RFA is now applied successfully to tumors
tures of 90°C are obtained for 4 to 6 minutes. If a portion of the up to 7 cm in diameter. Even larger hepatic tumors have been
nidus is not within 5 mm of the probe tip, the probe is reposi- ablated with RF.20 I have had the opportunity to RF ablate
tioned and the ablation repeated. The patient can then be re- pediatric liver metastases from colon cancer, rhabdomyosar-
covered and sent home. If the pain persists or recurs, a repeat coma, pancreatoblastoma, and hepatocellular carcinoma. This
ablation can be performed. RFA technique has been taken to the extreme when treating
One could safely perform the osteoid osteoma RF ablation carcinoid syndrome.21 Multiple hepatic lesions can be ablated
technique with the Cool-Tip system (Radionics) with a 1-cm at one time and remaining lesions can be treated at later ses-
active tip probe but with the cooling turned off. Cooling the tip sions, allowing regeneration of the liver between ablations. The
of the RF probe will burn a larger area (3 cm in diameter or volume of ablation is only limited by the risk of renal insuffi-
larger) than necessary and increase the risk of a delayed patho- ciency from tumor lysis, myoglobinuria, and hemoglobin-
logic fracture. Because this Radionics system is so precise, an uria22-24. The renal insufficiency may be avoided by aggressive
osteoid osteoma in the vertebral body neighboring the spinal hydration during and after RF ablation. Other manifestations of
canal has been safely treated with a noncooled RF probe with- tumor lysis syndrome include fever, nausea, pain, and fatigue.23
out spinal cord injury.18 Nondeployed multiprong or umbrella- Other complications of RFA include damage to neighboring
shaped probes should be avoided when treating osteoid os- bile ducts or bowel. These thin-walled systems may be burned
teoma at any location. The prongs cannot be fully deployed in and leak their contents. Patients who have had a prior biliary
the small nidus. The generated heat is distributed down the enteric anastomosis are at a high risk of developing a hepatic
shaft of the probe and may damage neighboring nerves or skin. abscess. They should understand the risks of RF ablation and be
Other manufacturers are now developing straight single-tip treated with prophylactic antibiotics.
probes for RF tumor ablation but usually coupled with infusion RFA of primary or metastatic lung cancer has been success-
ports that distribute saline in to the surrounding tissues and fully performed in adults25-28. Surgical excision of osteosar-
extend the diameter of the burn. Saline infusion should not be coma metastases to the lung does improve outcome.29 Surgery
used in conjunction with RF ablation for the osteoid osteoma. often finds multiple small lesions undetected by CT. However,
there may be diminishing returns for performing repeat thora-
cotomy for recurrent pulmonary metastases. Exposure of the
Radiofrequency Tumor Ablation in the entire pleural surface will become more difficult and thoraco-
Pediatric Patient scopic excision after pleural adhesions may be impossible.
I have gained experience performing RF ablation of pediatric There is a 91% recurrence rate of pulmonary osteosarcoma
tumors including in an open phase I protocol for RF ablation of metastases after initial thoracotomy30; 45% of the nodules recur
malignant tumors (usually metastases) in the liver, lung, and at the surgical scar. RFA of recurrent lesions may be warranted
musculoskeletal system acquired during childhood. Some tu- after the initial thoracotomy.


RFA of lung nodules can be performed with either cooled tip clonal cytogenetic aberrations in malignant soft tissue tumors. N Engl
probes or umbrella probes. Stroke from air embolus into the J Med 324:436-443, 1991
2. Hoffer FA, Gianturco LE, Fletcher JA, Grier HE: Percutaneous biopsy
pulmonary veins is a potential risk when performing RFA of the of peripheral primitive neuroectodermal tumors and Ewing’s sarco-
lung. Although there has been only one report of a stroke,27 one mas for cytogenetic analysis. AJR Am J Roentgenol 162:1141-1142,
study found small air emboli passing through the carotid artery 1994
during lung RFA without any clinical sequelae.28 I have ablated 3. Hoffer FA, Chung T, Diller L, Kozakewich H, Fletcher JA, Shamberger
pulmonary metastases in one patient with synovial sarcoma RC: Percutaneous biopsy for prognostic testing of neuroblastoma.
Radiology 200:213-216, 1996
using a triple-cluster Cool-Tip Radionics RF probe. 4. Shimada H, Chatten J, Newton WA, et al: Histological prognostic
Children do on occasion develop painful bone metastases. factors in neuroblastic tumors: Definition of subtypes of ganglioneu-
The pain of bone metastases in adults has been successfully roblastoma and age linked classification of neuroblastoma. J Natl
relieved by RFA.31,32 Even spinal metastases have been targeted Cancer Inst 73:405-416, 1984
with RFA. The lesion is approached from the long axis of the 5. Garrett KM, Hoffer FA, Behm FG, Gow KW, Hudson MM, Sandlund
JT: Interventional radiology techniques for the diagnosis of lym-
bone if possible. If the cortex is intact, a core biopsy can be phoma or leukemia. Pediatr Radiol 32:653-662, 2002
performed with a 14-G Trephine needle. This hole will allow a 6. Shamberger RC, Holzman RS, Griscom NT, Tarbell NJ, Weinstein
single-cooled tip RF probe to be placed in the bone. If the cortex HJ, Wohl ME: Prospective evaluation by computed tomography and
is thinned or disrupted, then a triple-cooled tip probe or an pulmonary function tests of children with mediastinal masses. Sur-
umbrella RF device can be placed. Lesions with diameters of 5 gery 118:468-471, 1995
7. Hoffer FA, Gow K, Flynn PM, Davidoff A: Accuracy of percutaneous
to 10 cm can be effectively ablated with these probes. Weight- lung biopsy for invasive pulmonary aspergillosis. Pediatr Radiol 31:
bearing lesions have also been treated with RFA when com- 144-152, 2001
bined with cementoplasty,32 which I would recommend if more 8. Saugier-Veber P, Devergie A, Sulahian A, Ribaud P, Traore F,
than one-third of the weight-bearing cortex is burned during Bourdeau-Esperou H, Gluckman E, Derouin F: Epidemiology and
the RF ablation. RF-ablated tissue shrinks just like cooked diagnosis of invasive pulmonary aspergillosis in bone marrow trans-
plant patients: Results of a 5 year retrospective study. Bone Marrow
meat. This allows space for the cement to be placed. Transplant 12:121-124, 1993
RF ablation may have a future role in controlling aggressive 9. Hoffer FA: Liver biopsy methods for pediatric oncology patients.
fibromatosis (desmoid tumors). These lesions are locally ag- Pediatr Radiol 30:481-488, 2000
gressive and recur after surgical resection. Radiotherapy and 10. Hardaway BW, Hoffer FA, Rao BN: Needle localization of small
chemotherapy33 have had limited success. There has been one pediatric tumors for surgical biopsy. Pediatr Radiol 30:318-322, 2000
11. Cioni D, Lencioni R, Bartolozzi C: Percutaneous ablation of liver
report of using acetic acid to ablate desmoid tumors not ame- malignancies: imaging evaluation of treatment response. Eur J Ul-
nable to surgical resection.34 The technique was staged so that trasound 13:73-93, 2001
the inner portion of the tumor was first ablated. The tumor then 12. Silverman SG, Tuncali K, Adams DF, Nawfel RD, Zou KH, Judy PF:
shrank away from vital structures, allowing for complete abla- CT fluoroscopy-guided abdominal interventions: Techniques, re-
sults, and radiation exposure. Radiology 212:673-681, 1999
tion. RF ablation could accomplish the same task. If there is a
13. Torriani M, Rosenthal DI: Percutaneous radiofrequency treatment of
contiguous vital nerve, the portion of the desmoid tumor that is osteoid osteoma. Pediatr Radiol 32:615-618, 2002
distant from the nerve could first be ablated. This may allow the 14. Rosenthal DI, Hornicek FJ, Wolff MW, Jennings LC, Gebhardt MC,
desmoid tumor to fall away from the nerve. Mankin HJ: Percutaneous radiofrequency coagulation of osteoid
RF ablation can damage central or peripheral nerves if tem- osteoma compared with operative treatment. J Bone Joint Surg
80:815-821, 1998
perature of the nerves exceeds 45°C. Because of this, osseous
15. Roger B, Bellin MF, Wioland M, Grenier P: Osteoid osteoma: CT-
RFA has been performed in adult patients under conscious guided percutaneous excision confirmed with immediate follow-up
sedation so that nerve stimulation can be detected. This would scintigraphy in 16 outpatients. Radiology 201:239-242, 1996
be impossible in pediatric patients. Other means of monitoring 16. Rosenthal DI: Percutaneous radiofrequency treatment of osteoid
nerve function in children under general anesthesia would be osteomas. Semin Musculoskelet Radiol 1:265-272, 1997
17. Pinto CH, Taminiau AHM, Vanderschueren GM, Hogendoorn PCW,
necessary. One can monitor the temperature near a major nerve
Bloem JL, Obermann WR: Technical considerations in CT-guided
or spinal canal using a percutaneously placed temperature radiofrequency thermal ablation of osteoid osteoma: Tricks of the
probe. One can avoid using paralytics during anesthesia to trade. AJR Am J Roentgenol 179:1633-1642, 2002
detect motor nerve stimulation. When contemplating RF abla- 18. Dupuy DE, Hong RJ, Oliver B, Goldberg SN: Radiofrequency ablation
tion of malignant tumors in the spine, one should choose le- of spinal tumors: Temperature distribution within the spinal canal.
AJR Am J Roentgenol 175:1263-1266, 2000
sions that are at least 1 cm away from the spinal canal to protect
19. Livraghi T, Solbiati L, Meloni MF, Gazelle GS, Halpern EF, Goldberg
the spinal cord. SN: Treatment of focal liver tumors with percutaneous radio-fre-
RFA has been performed in adults with renal cell carci- quency ablation: Complications encountered in a multicenter study.
noma.35,36 Peripheral renal lesions are more likely to be com- Radiology 226:441-451, 2003
pletely ablated without complications. The pediatric equivalent 20. Dupuy DE, Goldberg SN: Imaging-guided radiofrequency tumor ab-
lation: Challenges and opportunities—Part II. J Vasc Interv Radiol
would be perilobar nephroblastomatosis and bilateral Wilms’
12:1135-1148, 2001
tumor. Initially, nephron-sparing surgery would be most effi- 21. Gillams AR, Lees WR: Radiofrequency ablation of neuroendocrine
cacious. However, persistent or recurrent masses may be diffi- metastases. Radiology 221(P):627, 2001
cult to treat with surgical re-excision. RFA could potentially 22. Shankar S, VanSonnenberg E, Silverman SG, Tuncali K, Van Dam
treat the peripheral masses in the unresected kidney. Abbeele AD, Whang EE: Impact of treatment of large and multiple
hepatic lesions by percutaneous RF. Radiology 221(P):626, 2001
23. Rhim H, Choi J, Kim Y, Koh BH, Cho OK, Seo HS: Radiofrequency
ablation of hepatic tumors: Post-ablation syndrome. J Vasc Interv
References Radiol 11 (Suppl):271-272, 2000
24. Keltner JR, Donegan E, Hynson JM, Shapiro WA: Acute renal failure
1. Fletcher JA, Kozakewich HP, Hoffer FA, Lage JM, Weidner N, Tepper after radiofrequency liver ablation of metastatic carcinoid tumor.
RI, Pinkus GS, Morton CC, Corson JM: Diagnostic relevance of Anes Analg 93:587-589, 2001


25. Dupuy DE, Zagoria RJ, Akerley W, Mayo-Smith WW, Kavanagh PV, 31. Dupuy DE, Safran H, Mayo-Smith WW, Goldberg SN: Percutaneous
Safran H: Radiofrequency ablation of malignancies in the lung. AJR radiofrequency ablation of osseous metastatic disease. Radiology
Am J Roentgenol 174:57, 2000 202 (Suppl.):146, 1998
26. Sewell PE Jr., Vance RB, Wang YD: Assessing radiofrequency ab- 32. Schaefer O, Lohrmann C, Herling M, Uhrmeister P, Langer M: Com-
lation of non-small cell lung cancer with positron emission tomog- bined radiofrequency thermal ablation and percutaneous cemento-
raphy (PET). Radiology 217(P):334, 2000 plasty treatment of a pathologic fracture. J Vasc Inter Radiol 13:
27. Lee JM, Jin KY, Kim CS, Lee Y: Percutaneous radiofrequency 1047-1050, 2002
ablation for inoperable lung malignancies: a preliminary report. Ra- 33. Skapek SX, Hawk BJ, Hoffer FA, Dahl GV, Granowetter L, Gebhardt
diology 221(P):314, 2001 MC, Ferguson WS, Grier HE: Combination chemotherapy using
28. Rose SC, Fotoohi M, Levin DL, Harrell JH: Cerebral microemboliza- vinblastine and methotrexate for the treatment of desmoid tumor in
tion during radiofrequency ablation of lung malignancies. J Vasc Inter children. J Clin Oncol 16:3021-7, 1998
Radiol 13:1051-1054, 2002 34. Clark TWI: Percutaneous chemical ablation of desmoid tumors. J
29. Marina NM, Pratt CB, Rao BN, Shema SJ, Meyer WH: Improved Vasc Interv Radiol 14:629-633, 2003
prognosis of children with osteosarcoma metastatic to the lung(s) at 35. Gervais DA, McGovern FJ, Wood BJ, Goldberg SN, McDougal WS,
the time of diagnosis. Cancer 70:2722-2727, 1992 Mueller PR: Radiofrequency ablation of renal cell carcinoma: Early
30. McCarville MB, Kaste SC, Cain AM, Goloubeva O, Rao BN, Pratt CB: clinical experience. Radiology 217:665-672, 2000
Prognostic factors and imaging patterns of recurrent pulmonary 36. Dupuy DE, Mayo-Smith WW, Cronan JJ: Imaging-guided biopsy and
nodules after thoracotomy in children with osteosarcoma. Cancer radiofrequency ablation of renal masses. Sem Intervent Radiol 17:
91:1170-1176, 2001 373-379, 2000