BSIR IOUK Abstracts and Case Studies

Ibrahim Alshikmubarak, Rory Fairhead, Amr Elsaadany, Andrew White

Aim:
Departmental audit evaluating thermal ablation of hepatic lesions under image guidance (ultrasound and/or CT).
Outcomes were audited against CIRSE standard of practice (SOP) for thermal liver ablation and other clinical trials for safety, response and recurrence rate. Outcomes will also be separated according to disease HCC or liver metastases.
Materials and methods:
This is a retrospective analysis of liver ablations between the January 2021 to January 2025. Lesions included HCC and metastases. In the metastases group these were predominantly colorectal metastases (71%) but also included others such as breast, melanoma.
6 week post procedural CT findings reviewed to evaluate response at the ablation site and subsequent surveillance to assess later recurrence at the ablation site.
CIRSE grading system was used to assess complications.

Results:
A total of 196 lesions ablated with HCC (48%) and metastasis (52%). Microwave was the predominant mode of ablation. Considering all ablations, complete response (CR) rate at first scan is 80%. CR rates were higher when CT was used with CRR of 86% and 76% with US alone.
Overall recurrence at ablation site in those that achieved CR at first scan was 20%.
Response rates for HCC and metastases separately will be presented.
Major complication rate was 2.7%.

Conclusion:
Our initial results show comparable outcomes to the CIRSE SOP for safety. Response rate and recurrence is comparable to those in the literature, although for early-stage HCC our CR rate is lower than expected. This will be discussed. Findings suggest utilising CT yields higher CR rates.

Jun Li Tham, Jim Zhong, Hamish Glencross, Jerome Occidental, Jacqueline Brandon, Bali Bhambra, Paul Underwood, Victoria Boardman, Hazem Elahmedawy, Omar Abdel-Hadi, Jonathan Smith, James Lenton, Tze Wah

Aims
To explore the multidisciplinary interventional oncology (IO) team perspectives on barriers and facilitators to adopting a robotic navigation platform for CT-guided tumour ablation.

Materials and methods
Qualitative study conducted at a tertiary IO centre performing over 200 CT-guided ablations (liver, kidney and lung) annually. Following the introduction of the Epione® robotic-assisted platform (Quantum Surgical), semi-structured interviews were conducted with members of the IO team, including interventional radiologists (n=5), anaesthetists (n=4), clinical nurse specialists (n=3), operating department practitioner (n=2), and radiographers (n=2). Interviews explored workflow integration, perceived benefits, logistical challenges, training needs, and broader implications for service delivery. Interviews were audio-recorded, transcribed verbatim, and analysed using reflexive thematic analysis following iterative coding.

Results
Operators perceived that robotic guidance could facilitate more precise (multi)needle placement helped by respiratory tracking capabilities, optimised visualisation of needle trajectories and treatment zones, and potentially increasing future case volume. Early engagement with all members of IO team and hands-on training were key facilitators to successful adoption. Workflow adaptations included longer breath-holds during anaesthesia and increased procedural communication. Logistical challenges included limited CT suite space and equipment positioning, overcome by designing room floor plans and standardising equipment positioning. Procedures were longer during the learning phase but improved with experience and manufacturer support. Additional concerns included financial cost, training requirements, and potential de-skilling in manual needle placement techniques.

Conclusion
Adoption of robotic navigation for tumour ablation is influenced by technical, organisational, and multidisciplinary workflow factors. Understanding team perspectives through early engagement highlights practical considerations that facilitate safe and effective implementation of new technologies.

Charlie Haslam, Emma Routledge, Peter Littler, David McCulloch, Yiannis Skarparis, Louise Macdougall, Rohan Thakkar, Helen Reeves

Aims:

Selective internal radiation therapy (SIRT) delivered as radiation segmentectomy for HCC enables delivery of ablative-intent radiation to a targeted perfused volume while preserving uninvolved liver. We evaluated the safety, dosimetry, and early radiological outcomes of SIRT segmentectomy in a single-centre cohort, with comparison to the LEGACY data.

Materials and Methods:

Retrospective analysis of 18 SIRT segmentectomy procedures in 16 patients with HCC, conducted following institutional approval. Data included demographics, tumour characteristics, post-dosimetry parameters (Bremsstrahlung SPECT imaging), liver function trends, complications. Radiological response was assessed at 1, 3, 6, 9, and 12 months post-treatment. Absorbed doses are reported with limited inherent precision.

Results:

Cohort was 69% male with a median age of 77 years; 83% had cirrhosis. Median tumour size 48 mm, larger than in LEGACY (27 mm). Mean planned and delivered absorbed doses 430 Gy and 450 Gy, respectively, with a mean perfused liver volume of 13%. Procedural best objective response rate (B-ORR) was 94% (17/18), comprising CR in 33% (6/18) and PR in 61% (11/18). Patient-level best-response ORR was 94% (15/16), comprising CR in 38% (6/16), PR in 56% (9/16), and progression in 6% (1/16), comparable to 88% in LEGACY. Two patients underwent repeat SIRT with further response. Mean tumour absorbed dose was higher in CR (1100 Gy) than PR (690 Gy). Liver function remained stable; no hepatic decompensation. Two complications occurred (CIRSE grades 1b and 3a).

Conclusion:

SIRT segmentectomy achieved high local tumour control comparable to LEGACY, with favourable safety profile consistent with published data despite larger tumour size.

Vinson Wai-Shun Chan, Blair Graham, Helen Hoi-Lam Ng, Scott Griffiths, Deevia Kotecha, Hanif Ismail, Paul Jenkins, Jim Zhong, Raghuram Lakshminarayan, Tze Min Wah

Aims:
Interventional Oncology (IO) offers a diverse range of minimally invasive, precise and targeted cancer therapies. Despite its transformative potential, research within the field often lacks a unified strategic direction. In an environment of limited funding and resources, there is a critical risk of fragmented efforts and the misallocation of research capital toward questions that may not align with the priorities of the clinical or patient communities. The DEFINE-IO study aims to identify the most pressing research priorities in IO to guide researchers, policy makers, and funding bodies in driving innovation and improving cancer outcomes.

Materials and Methods:
The DEFINE-IO study employs a rigorous, two-phase methodology to establish the first national research strategy for the discipline. Phase 1 utilises a three-round modified e-Delphi process to generate research topics and achieve expert consensus. Following the refinement of topics, the top 25 priorities will undergo Phase 2: a multi-Criteria Decision Analysis (MCDA). During an in-person session, these priorities will be evaluated against three predefined criteria: Urgency, Feasibility/Equipoise and Affordability. This dual-phase approach ensures that the final rankings account for both scientific importance and real-world deliverability.

Ethics, output and dissemination:
Formal ethics approval was deemed not necessary. The final "strategic roadmap" will be disseminated through peer-reviewed publications and presentations at major national conferences. By identifying the most pressing clinical and scientific questions, DEFINE-IO aims to guide researchers, policymakers, and funding bodies in driving innovation and optimising cancer care delivery. Recruitment is now complete and full results are expected November 2026.

Smarth Batra, Dr Alexander King, Dr Brian Stedman

Thermal ablation is an established minimally invasive treatment for colorectal liver metastases (CRLM), particularly in patients unsuitable for surgical resection. Evidence from the COLLISION trial demonstrates that adjunctive hepatic artery catheterisation improves local tumour progression-free survival; however, its adoption across UK centres remains limited.
We present our institutional experience demonstrating the technical and economic advantages of incorporating hepatic artery catheterisation into routine ablation practice. Selective arterial catheterisation improves lesion conspicuity and enables accurate delineation of tumour margins, facilitating optimal probe placement and confident achievement of adequate ablative margins. This enhanced precision reduces the risk of residual disease and local recurrence.

From a resource perspective, hepatic artery catheterisation requires minimal additional equipment, typically a sheath, catheter, guidewire, and a small volume of contrast. In contrast, incomplete ablation results in substantial downstream costs, including repeat hospital admissions, additional procedures under general anaesthesia, and potential salvage surgery, increasing both healthcare burden and patient morbidity.

In the current NHS climate, with a growing emphasis on value-based care, hepatic artery catheterisation represents a low-cost, high-impact adjunct to ablation. Wider adoption across interventional oncology centres has the potential to improve oncological outcomes while delivering meaningful cost savings.
Patient consent and institutional review board were not obtained as these were not deemed necessary for this study.

Helen Hoi-Lam Ng, Vinson Wai-Shun Chan, Ashwin Mahendra, Govindarajan Narayanan, Jose Maria Abada

Aims:
Image-guided ablation (IGA) of central, endophytic and hilar kidney tumours close to vital structures remains a major clinical challenge. This study evaluates real world outcomes of irreversible electroporation (IRE) for small renal cell carcinomas (RCCs) deemed unsuitable for surgery or conventional thermal ablation.

Method and Materials:
This retrospective analysis utilised a prospectively maintained database from three specialist centres (USA, UK, Spain) for patients undergoing percutaneous IRE (NanoKnife System, Angiodynamics) for biopsy proven RCC between May 2015 and October 2024. Patients were selected via multidisciplinary team discussion, typically due to tumour proximity to vital structures, solitary kidneys, significant comorbidities, or prior interventions.

Results:
68 patients (mean age 66.9 years; SD 12.3) with 71 tumours were included. Mean tumour size was 3.01 cm (SD 1.15) and mean RENAL Nephrometry score was 9 (SD 6-9). Technical success was 100%. Primary technique efficacy was 77.5% (55/71), with a local control rate of 95.8% (68/71). Two major complications (2.8%; ureteric injury and haematuria) were observed. Mean eGFR change was -5.12 ml/min/1.73m², with 10.1% of patients seeing a >25% reduction. At 59-month mean follow-up (SD 35), 5-year Local Tumour Progression-Free Survival was 84.4% (95% CI 71.8-91.7%). The trifecta outcome (achievement of primary efficacy, absence of major complications, and <25% eGFR decline) was achieved in 69.0% of cases.

Conclusion:
IRE is safe and effective as a problem-solving technique for managing renal tumours, where they are near vital structures and are unsuitable for surgery or other ablation modalities. Further prospective studies and longer-term data comparing IRE to surgery or other modalities are

Vinson Wai-Shun Chan, Helen Hoi-Lam Ng, Jim Zhong, Peter Culmer, Helen Hughes, Tze Min Wah

Aims:
Procedural-heavy environments such as in interventional oncology (IO) contribute significantly to medical waste. The environmental impact of IO procedures is underexplored. This study aims to evaluate waste generation and carbon emissions to address the environmental impact of IO, thus, to drive evidence-based sustainable practice for the future of the speciality.

Study design:
This will be a prospective, interdisciplinary feasibility study investigating the environmental and behavioural drivers of medical waste within image-guided tumour ablation procedures at a high-volume, tertiary academic centre. The study will utilise a "cradle-to-grave" Life Cycle Assessment (LCA) to quantify CO2 equivalent emissions per ablation procedure. Concurrently, ethnographic observations and staff workshops (n=4) will be conducted to identify behavioural barriers. These insights will inform the co-design of two targeted interventions: operational changes (e.g., closed-loop recycling and reusable instrument trials) and behavioural "nudges" (e.g., real-time prompts and visual cues).
The primary endpoint is the quantitative reduction in greenhouse gas emissions and waste volume, validated via a repeat LCA. Secondary endpoints include staff adherence to new protocols and the feasibility of co-designed interventions in high-stakes clinical workflows.

Output and Dissemination:
This study is expected to provide the first comprehensive carbon footprint analysis specific to IO ablation procedures. The final dataset will offer an open-access "sustainability toolkit", which can be adopted by other centres, demonstrating that integrating behavioural science with operational shifts can significantly mitigate the environmental impact of resource-intensive IR procedures.
This is classified as an audit/ qualitive improvement project hence ethical approval is not deemed necessary.

Jakki Brandon, Hamish Glencross, Jerome Occidental, Balbir Bhambra, Clifford Powell, Jason Mort, Michael Gallagher, Dr Victoria Boardman, Dr Paul Underwood, Dr Hazem Elahmedawy, Dr John Stones, Dr Jim Zhong, Dr Omar Abdel-Hadi, Dr James Lenton, Dr Jon Smith, Professor Tze Min Wah

Aims:
• Identify key components of an effective onboarding process for a robotic assistance system in interventional oncology.
• Describe strategies enabling rapid and safe clinical adoption of robotic guidance for percutaneous image-guided ablation procedures.

Materials and Methods:
Robotic assistance improves accuracy and reproducibility in percutaneous image-guided interventions. This report outlines the structured implementation of a robotic guidance system within a UK interventional radiology (IR) unit and the organizational factors facilitating rapid clinical integration.

Results: A robotic system (Epione, Quantum Surgical, Montpellier, France) was installed on 25 September 2025. The first 48 robotic assistance procedures were performed in multiple organs (liver=34; kidney=11; lung=3) and ablation modalities (microwave=31; cryoablation=12; radiofrequency=1; irreversible electroporation (IRE)=4). Multi-needle placement (around 50% cases; with 1-7 needles insertion) was routinely performed. Technical feasibility and early clinical success were consistently achieved in 96% by all five IRs with varying experience (1->20 years).

Successful implementation required early engagement of all stakeholders: IRs, clinical and research specialist nurses, radiographers, and anaesthesiologists. Preparatory steps included structured procurement, comparative evaluation of available technologies, and consensus choice of the device to acquire. The selected robot offered high accuracy, multi-needle capability, and broad organ applicability, aligning with departmental needs.

Results: Comprehensive team training and previous experience with another navigation device enabled immediate integration into routine practice. Within three months, the system showed value for complex lesion targeting, strengthening trust and supporting expansion to more challenging cases.

Conclusion: Coordinated multidisciplinary engagement and structured onboarding enable rapid, safe adoption of robotic assistance, facilitating clinical expansion and service development.

Jakki Brandon, Hamish Glencross, Jerome Occidental, Balbir Bhambra, Amanda Yang, Dr Victoria Boardman, Dr Paul Underwood, Dr Jim Zhong, Dr Omar Abdel-Hadi, Dr James Lenton, Dr Jonathan Smith, Professor Tze Min Wah

Aims: To describe the set-up process for electrochemotherapy (ECT) with bleomycin as a new interventional procedure to treat liver tumours, and the pathway development to ensure the safe delivery and patient care.

Materials and methods

BECT has been used at Leeds Cancer Centre to treat melanoma and vascular malformations for several years. To gain approval for the indication of liver tumours required application to the New Interventional Procedure Group (NIPG), Drug and Therapeutic Group (DTG) and the Systemic Anticancer Therapy (SACT) steering group.

A Standard Operating Procedure (SOP) was developed to guide the entire patient pathway from referral through to follow up. Key points were the screening and consent process, prescribing, dispensing and administering of bleomycin, perioperative care and follow up.

Communications and educational materials were developed and disseminated to the MDT and relevant departments involved in the patient pathway.

Results

We received local and national referrals and identified patients eligible for ECT. This enabled concurrent enrolment into the REgiStry for Percutaneous ElectroChemoTherapy (RESPECT).

Collaboration between interventional oncology, medical oncology, clinical education, pharmacy, anaesthesia, the perioperative team, and industry partner enabled safe and efficient delivery of the treatment.

Following the procedure, we conducted debrief communications and a lessons learnt process.

Conclusion

Through securing approvals and the formulation of a robust SOP in conjunction with coordinated multidisciplinary engagement, this enabled safe and efficient care delivery. Thus, facilitating clinical expansion, service development and providing a new interventional treatment option for suitable patients.

Jakki Brandon, Marta Kurzawa, Yudish Rughooputh, Emma West, Dr Jim Zhong, Professor Adel Samson, Professor Tze Min Wah, Dr Naveen Vasudev

Aims:
The POLAR trial will investigate cryoablation in combination with standard of care doublet immune checkpoint inhibitor (ICI) in patients with metastatic renal cell carcinoma (mRCC). Cryoablation is routinely employed in the management of patients with localised, small renal tumours. Thus, the novelty of this study is in combining these two established therapies in the setting of mRCC to understand any synergistic effects.

Materials/Methods:
POLAR will combine standard of care ipilimumab plus nivolumab for mRCC with cryoablation. All participants must be willing and able to undergo cryoablation, between cycle 1 and cycle 2 of their treatment.

Planned sample size is 12. Follow up duration is 12 months.

Results:
Study endpoints:

To characterise the safety of the combination of ICI plus cryoablation in mRCC

To measure immunogenic cell death in response to ICI plus cryoablation

To assess overall response rate

To assess the median progression free survival (PFS)

To assess landmark 12m PFS

To assess landmark 12m overall survival.

Tissue and blood-based immune monitoring assays

Conclusion:

Whilst ICI-based therapy can offer the potential for durable disease control in mRCC, many patients’ cancers do not respond, and novel strategies are urgently needed. Early preclinical and clinical studies demonstrate synergistic enhancement of anti-cancer immune response when combining immunotherapy with cryoablation, but potential patient benefit needs to be more thoroughly investigated in further trials.

This feasibility study will provide insight into the combination therapy strategy between cryoablation and immunotherapy, potentially widening the scope for cryoablation to include patients with mRCC.

Rathna Bhargavi Veerni, Dr Frank Carey

Background
Percutaneous thermal ablation is an established treatment for primary and secondary liver tumours, offering local control with lower morbidity than surgical resection. The COLLISION trial demonstrated non-inferior survival and superior safety versus surgery for colorectal liver metastases (CRLM) ≤3 cm. For hepatocellular carcinoma (HCC), ablation is first-line treatment in early and very early BCLC stage disease. Tumour size, ablation margin and vessel proximity are recognised determinants of recurrence, and margin assessment reduces local recurrence.

Aim
To assess recurrence after percutaneous microwave ablation (MWA) for hepatobiliary tumours and evaluate associations with tumour size, vessel proximity and ablation confirmation.

Methods & Materials
Retrospective single-centre analysis of lesions treated with CT-guided percutaneous MWA over 6 years. The unit of analysis was the lesion. Recurrence was defined as local or intrahepatic recurrence on follow-up imaging. Twelve-month recurrence was estimated by Kaplan-Meier. Associations with size, vessel proximity and ablation confirmation were assessed by multivariable logistic regression.

Results
129 lesions (83 HCC, 24 CRLM, 22 other) were ablated across 113 sessions in 90 patients (median age 70; 78% male; median diameter 2.1 cm). 25% of sessions included intra-procedural ablation confirmation. Per-lesion recurrence was 17.1% (95% CI 11.4–24.7): HCC 19.5%, CRLM 8.7% (p=0.35). Twelve-month recurrence was 6.6% (HCC 8.7%; CRLM 0%). On multivariable analysis, neither size (aOR 1.01, 95% CI 0.58–1.78), vessel proximity (aOR 0.65, 0.19–2.29), nor ablation confirmation (aOR 0.55, 0.15–2.05) was significantly associated with recurrence.

Conclusion
Outcomes were consistent with published series. The directional trend toward reduced recurrence with ablation confirmation warrants evaluation in larger cohorts. This audit was locally approved and registered.

Francesca McKee, Ching Foo

Aims:

Percutaneous transhepatic cholangiography (PTC) is performed for biliary obstruction following unsuccessful endoscopic retrograde cholangiopancreatography, but carries significant infectious complication rates of 19–43%. This audit assessed adherence to prophylactic antimicrobial protocols and post-procedural bacteraemia rates at a single centre.

Methods:

Retrospective analysis of 100 consecutive PTCs performed between January and November 2024. Data collected included prophylactic antibiotic administration (agents, route, dose, timing), time of biliary access via fluoroscopic imaging and presence of bacteraemia within 30 days post-procedure. Expected standards were 100% prophylactic antibiotic coverage and administration within 60 minutes of biliary access.

Results:

Procedures were performed on 68 patients. Twenty percent of procedures (n=20) involved patients already on regular antibiotics. Among the remaining 80 procedures, 99% received prophylactic antibiotics, administered a mean of 36 minutes before intervention. However, only 90% received antibiotics within the 60-minute target window; notably, none of the eight patients receiving antibiotics beyond this timeframe developed bacteraemia. Overall, 16% of patients (n=11) developed bacteraemia within 30 days. Among these, four were on regular antibiotics pre-procedure, of which, three demonstrated bacterial resistance to at least one pre-procedural agent.

Conclusions:

Adherence to prophylactic antibiotic administration was high (99%), though timing compliance fell short of the 100% standard at 90%. The 16% post-procedural bacteraemia rate is comparable to published literature. No association was observed between delayed antibiotic administration and subsequent bacteraemia, though antimicrobial resistance patterns in patients developing infection warrant further investigation.

Thomas Watkinson

Case report

A 70-year-old female, with a background of previously treated bilateral breast cancers, presented with right shoulder pain and dyspnoea. Her initial CT imaging demonstrated a large right upper lobe lung mass with mediastinal lymphadenopathy, and a solitary 31 mm lesion in segments 2–3 of the liver (Image 1). Findings were consistent with lung cancer, staged as T4 N1 M1, with presumed hepatic metastasis.

Further evaluation with contrast-enhanced MRI showed a 36 mm segment 2 lesion demonstrating arterial phase hyperenhancement and early venous phase washout, raising suspicion for a synchronous hepatocellular carcinoma (HCC) (Image 2).

Ultrasound-guided biopsy confirmed a moderately differentiated HCC with granulomatous change on a background of hepatic steatosis.

Multidisciplinary Planning and Pre-Procedural Assessment:

Following multidisciplinary discussion, selective internal radiation therapy (SIRT) was recommended with curative intent using a radiation segmentectomy approach targeting the left lateral segment as this is better tolerated with quicker recovery and less side effects compared to a TACE procedure.

Pre-treatment planning angiography with Tc-99m MAA demonstrated avid tumour uptake with appropriate distribution to segments 2 and 3 and a lung shunt fraction of 0% (image 3).

Treatment and Dosimetry:

SIRT was performed using Yttrium-90 glass microspheres (TheraSphere®), delivered via the left hepatic artery (image 4).

Dosimetric analysis demonstrated:
• Perfused volume 464 ml.
• Planned perfused absorbed dose to the perfused volume was 401 Gy.

Post-therapy Bremsstrahlung SPECT-CT, acknowledging inherent imaging limitations, confirmed appropriate intrahepatic distribution and estimated a tumour absorbed dose of approximately 1360 Gy.

The procedure was well tolerated, and the patient was discharged the following day without complication.

Follow-Up and Outcomes:

One-month post-treatment quad-phase CT demonstrated complete devascularisation of the lesion, consistent with complete radiological response (image 5).
Subsequent imaging at 3, 4, and 9 months showed progressive involution with no residual enhancement. The treated segments became hyperattenuating with volume loss, in keeping with expected post-radiation segmentectomy changes (image 6).
The patient remains under ongoing CT surveillance.

Discussion
This case demonstrates the effectiveness of ablative-dose SIRT in achieving complete response in solitary HCC. The high tumour absorbed dose supports its role as a curative-intent therapy.
A key feature in this case is the presence of synchronous malignancy. The patient successfully underwent SIRT alongside neo-adjuvant chemoimmunotherapy and subsequent surgical resection for lung adenocarcinoma, without delay to either treatment pathway.

Conclusion

Ablative SIRT is a safe and effective curative option for early-stage HCC and can be successfully integrated into complex oncological management, including cases with synchronous primary malignancies.

Jakki Brandon

What – description of the experience

This case study reflection is on the set-up process for electrochemotherapy with bleomycin (B-ECT) as a new interventional procedure to treat liver tumours, through to the successful completion of our first case.

B-ECT has been used at Leeds Cancer Centre to treat melanoma for several years. However, approval for treatment of liver tumours required application to the New Interventional Procedure Group (NIPG), Drug and Therapeutic Group (DTG) and the Systemic Anticancer Therapy (SACT) steering group.

With collaboration and support from key stakeholders, I developed a Standard Operating Procedure (SOP) to guide the entire patient pathway from referral through to follow up. Communications and educational materials were developed and disseminated to the multidisciplinary team (MDT) and relevant departments involved in the patient pathway.

So what – the significance of the experience

We received local and national referrals. The first case identified as eligible was a 92-year-old female with a 5.5cm centrally located liver metastasis within segment VI/VII. She currently continued to have good quality of life and had previously been referred for Stereotactic Body Radiation Therapy (SBRT), but this was not possible due the small size of the liver and significant breathing motion. The only alternative treatment option offered was systemic palliative therapy.

After MDT discussion she was referred, screened and assessed as suitable for B-ECT treatment.

Collaboration between interventional oncology, medical oncology, clinical education, pharmacy, anaesthesia, the perioperative team, and industry partner enabled us to safely and efficiently delivery our first B-ECT treatment. This also enabled concurrent enrolment into the REgiStry for Percutaneous ElectroChemoTherapy (RESPECT).

Now what – insights and lessons learnt

Throughout the set-up process there were several priorities to consider and address –financial assurances, logistics and resource management, staff knowledge and training, staff safety and, primarily patient safety and the patient pathway.

When I encountered obstacles, I kept the patient at the heart of what we were aiming for. I had to reinforce the need and the value of this treatment to stakeholders and give reassurance that throughout the process we would ensure effective communication and collaboration and that patient safety would be paramount.

The case itself provided numerous learning points. It was technically challenging and involved numerous new processes including the use of robotic needle guidance for an ECT procedure, the delivery, handling and administration of SACT in this setting and it required the inclusion of many different personnel in the operating room at one time.

Following the procedure, I facilitated debrief communications and a lesson learnt process, which was disseminated throughout the team.

Through securing approvals, the formulation of a robust SOP and coordinated multidisciplinary engagement, this enabled safe and efficient care delivery for this patient. Furthermore, this has facilitated clinical expansion, service development and provides an additional interventional treatment option for suitable patients.

Written consent was gratefully received from the patient to share details and images for publication and education purposes.