Preoperative Embolization of Hypervascular Castleman's Disease of the Mediastinum

We report the case of a 31-year-old woman with mediastinal Castleman's disease of the hyaline vascular type. This large tumor was safely resected after arterial embolization. We describe the steps of this interventional procedure and discuss related necessary precaution

Transarterial embolization in acute colonic bleeding: review of 11years of experience and long-term results

Background: Lower gastrointestinal bleeding represents 20% of all gastrointestinal bleedings. Interventional radiology has transformed the treatment of this pathology, but the long-term outcome after selective embolization has been poorly evaluated. The aim of this study is thus to evaluate the short-term and long-term outcomes after selective embolization for colonic bleeding. Methods: From November 1998 to December 2010, all acute colonic embolizations for hemorrhage were retrospectively reviewed and analyzed. The risk factors for post-embolization ischemia were also assessed. Results: Twenty-four patients underwent colonic embolization. There were 6 men and 18 women with a median age of 80years (range, 42-94years). The underlying etiologies included diverticular disease (41.9%), post-polypectomy bleeding (16.7%), malignancy (8.2%), hemorrhoid (4.1%), and angiodysplasia (4.1%). In 23 patients, bleeding stopped (95.8%) after selective embolization. One patient presented a recurrence of bleeding with hemorrhagic shock and required urgent hemorrhoidal ligature. Four patients required an emergent surgical procedure because of an ischemic event (16.7%). One patient died of ileal ischemia (mortality, 4.1%). The level of embolization and the length of hypoperfused colon after embolization were the only risk factors for emergent operation. Mean hospital stay was 18days (range, 9-44days). After a mean follow-up of 28.6months (range, 4-108months), no other ischemic events occurred. Conclusion: In our series, selective transarterial embolization for acute colonic bleeding was clinically effective with a 21% risk of bowel ischemia. The level of embolization and the length of the hypoperfused colon after embolization should be taken into consideration for emergent operatio

Image-guided multipolar radiofrequency ablation of liver tumours: initial clinical results

The local effectiveness and clinical usefulness of multipolar radiofrequency (RF) ablation of liver tumours was evaluated. Sixty-eight image-guided RF sessions were performed using a multipolar device with bipolar electrodes in 53 patients. There were 45 hepatocellular carcinomas (HCC) and 42 metastases with a diameter ≤3cm (n = 55), 3.1-5cm (n = 29) and >5cm (n = 3); 26 nodules were within 5mm from large vessels. Local effectiveness and complications were evaluated after RF procedures. Mean follow-up was 17 ± 10months. Recurrence and survival rates were analysed by the Kaplan-Meier method. The primary and secondary technical effectiveness rate was 82% and 95%, respectively. The major and minor complication rate was 2.9%, respectively. The local tumour progression at 1- and 2-years was 5% and 9% for HCC nodules and 17% and 31% for metastases, respectively; four of 26 nodules (15%) close to vessels showed local progression. The survival at 1year and 2years was 97% and 90% for HCC and 84% and 68% for metastases, respectively. Multipolar RF technique creates ablation zones of adequate size and tailored shape and is effective to treat most liver tumours, including those close to major hepatic vessel

Radiofrequency ablation of small liver malignancies under magnetic resonance guidance: progress in targeting and preliminary observations with temperature monitoring

Objectives: To evaluate the feasibility and effectiveness of magnetic resonance (MR)-guided radiofrequency (RF) ablation for small liver tumours with poor conspicuity on both contrast-enhanced ultrasonography (US) and computed tomography (CT), using fast navigation and temperature monitoring. Methods: Sixteen malignant liver nodules (long-axis diameter, 0.6-2.4cm) were treated with multipolar RF ablation on a 1.5-T wide-bore MR system in ten patients. Targeting was performed interactively, using a fast steady-state free precession sequence. Real-time MR-based temperature mapping was performed, using gradient echo-echo planar imaging (GRE-EPI) and hardware filtering. MR-specific treatment data were recorded. The mean follow-up time was 19 ± 7months. Results: Correct placement of RF electrodes was obtained in all procedures (image update, <500ms; mean targeting time, 21 ± 11min). MR thermometry was available for 14 of 16 nodules (88%) with an accuracy of 1.6°C in a non-heated region. No correlation was found between the size of the lethal thermal dose and the ablation zone at follow-up imaging. The primary and secondary effectiveness rates were 100% and 91%, respectively. Conclusions: RF ablation of small liver tumours can be planned, targeted, monitored and controlled with MR imaging within acceptable procedure times. Temperature mapping is technically feasible, but the clinical benefit remains to be prove

Unusual Masses of the Pancreas to Be Aware of

This paper aims at emphasizing the difficulty in assessing preoperatively the diagnosis of solid masses of the pancreas whatever the initial clinical presentation may be. We illustrate our purpose describing consecutive cases of pancreatic masses of the pancreas we recently had and who were followed according to the internal guidelines of investigation of our referral hospital. Whereas malignant tumors of the pancreas represent the vast majority of solid tumors of the pancreas, other diagnoses must be evoked. We report three cases of pancreatic solid masses that were explored by endoscopic ultrasonography coupled with fine needle aspiration, a method universally considered to be both reliable and accurate but which failed to assess definitive diagnosis due to both cytological pitfalls and sampling error

Biliary Involvement in Type 2 Autoimmune Pancreatitis

Autoimmune pancreatitis (AIP) is a rare condition classified in 2 subtypes. Their distinction relies on a combination of clinical, serological, morphological and histological features. Type 1 is a pancreatic manifestation of IgG4-related disease characterized by multiorgan infiltration by IgG4 plasmocytes. In this condition, hepatobiliary infiltration is frequent and often mimics cholangiocarcinoma or primary sclerosing cholangitis. On the other hand, type 2 is commonly limited to the pancreas. Herein, we describe the case of a patient who presented a type 2 AIP associated with cholangiopathy, a condition not described in the established criteria. He first developed a pancreatitis identified as type 2 by the typical histopathological features and lack of IgG4 in the serum and tissue. Despite a good clinical response to steroids, cholestasis persisted, identified by MR cholangiography as a stricture of the left hepatic duct with dilatation of the intrahepatic bile duct in segments 2 and 3. Biliary cytology was negative. Evolution was favorable but after steroid tapering a few months later, the patient suffered from recurrence of the pancreatitis as well as progression of biliary attempt, suspicious for cholangiocarcinoma. As the investigations again ruled out neoplastic infiltration or primary sclerosing cholangitis, azathioprine was initiated with resolution of both pancreatic and biliary attempts

Improved Long-Term Outcome of Surgery for Advanced Colorectal Liver Metastases: Reasons and Implications for Management on the Basis of a Severity Score

Background: The outcome of liver resection for colorectal liver metastases (CRLM) appears to be improving despite the fact that surgery is offered to patients with more-severe disease. To quantify this assumption and to understand its causes we analyzed a series of patients on the basis of a standardized severity score and changes in management occurring over the years. Methods: Patients' characteristics, operative data, chemotherapies and follow-up were recorded. CRLM severity was quantified according to Fong's clinical risk score (CRS), modified to take into account the presence of bilateral liver metastases. Three periods were analyzed, in which different indications, surgical strategies and uses of chemotherapy were applied: 1984-1992, 1993-1998, and 1999-2005. Results: Between January 1984 and December 2005, 210 liver resections were performed in 180 patients (1984-1992, 43 patients; 1993-1998, 42 patients; 1999-2005, 95 patients). CRLM severity increased throughout the time periods, as did the use of neoadjuvant chemotherapies, repeat resections, and multistep procedures. While the disease-free survival did not improve over time, the 1-, 3- and 5-year overall survival rate increased from 85%, 30%, and 23% in the first period, to 88%, 60%, and 34% in the second period, and to 94%, 69%, and 46% in the third period. Conclusions: Analysis according to the CRS showed that despite the fact that patients had more severe disease, the overall survival improved over the years, mainly thanks to more aggressive treatment of recurrent disease. Management of advanced CRLM should, from the start, take into account the likelihood of secondary procedure

Prospective randomized study of doxorubicin-eluting-bead embolization in the treatment of hepatocellular carcinoma: results of the PRECISION V study.

Transcatheter arterial chemoembolization (TACE) offers a survival benefit to patients with intermediate hepatocellular carcinoma (HCC). A widely accepted TACE regimen includes administration of doxorubicin-oil emulsion followed by gelatine sponge-conventional TACE. Recently, a drug-eluting bead (DC Bead) has been developed to enhance tumor drug delivery and reduce systemic availability. This randomized trial compares conventional TACE (cTACE) with TACE with DC Bead for the treatment of cirrhotic patients with HCC. Two hundred twelve patients with Child-Pugh A/B cirrhosis and large and/or multinodular, unresectable, N0, M0 HCCs were randomized to receive TACE with DC Bead loaded with doxorubicin or cTACE with doxorubicin. Randomization was stratified according to Child-Pugh status (A/B), performance status (ECOG 0/1), bilobar disease (yes/no), and prior curative treatment (yes/no). The primary endpoint was tumor response (EASL) at 6 months following independent, blinded review of MRI studies. The drug-eluting bead group showed higher rates of complete response, objective response, and disease control compared with the cTACE group (27% vs. 22%, 52% vs. 44%, and 63% vs. 52%, respectively). The hypothesis of superiority was not met (one-sided P = 0.11). However, patients with Child-Pugh B, ECOG 1, bilobar disease, and recurrent disease showed a significant increase in objective response (P = 0.038) compared to cTACE. DC Bead was associated with improved tolerability, with a significant reduction in serious liver toxicity (P &lt; 0.001) and a significantly lower rate of doxorubicin-related side effects (P = 0.0001). TACE with DC Bead and doxorubicin is safe and effective in the treatment of HCC and offers a benefit to patients with more advanced disease