Locoregional Therapies for Hepatocellular Carcinoma prior to Liver Transplant: Comparative Pathologic Necrosis, Radiologic Response, and Recurrence

PURPOSE

To compare pathologic tumor necrosis rates after locoregional therapies (LRTs) for hepatocellular carcinoma (HCC) prior to liver transplantation and evaluate radiologic-pathologic correlation along with posttransplant HCC recurrence.

MATERIALS AND METHODS

Consecutive patients with solitary HCC bridged or downstaged with LRT from 2010 to 2022 were included. LRTs were transarterial chemoembolization (TACE), radioembolization (yttrium-90 [90Y]), ablation, and stereotactic body radiotherapy (SBRT). Upfront combination therapy options were TACE/ablation and TACE/SBRT. Subsequent therapy crossover due to local recurrence was allowed. Posttreatment imaging closest to the time of transplant, explant histopathologic necrosis, and tumor recurrence after transplant were reviewed.

RESULTS

Seventy-three patients met inclusion criteria, of whom 5 (7%) required downstaging. 90Y alone (n = 36) and multimodal therapy (pooled upfront combination and crossover therapy, n = 23) resulted in significantly greater pathologic necrosis compared with TACE alone (n = 14; P = .01). High dose 90Y radiation segmentectomy (≥190 Gy; n = 27) and TACE/ablation (n = 7) showed highest rates of complete pathologic necrosis (CPN)-63% (n = 17) and 71% (n = 5), respectively. Patients with CPN had a mean lesion size of 2.5 cm, compared with 3.2 cm without CPN (P = .04), irrespective of LRT modality. HCC recurrence was more common in patients without CPN (16%, 6/37) than in those with CPN (3%, 1/36; P = .11). Using Liver Imaging Reporting and Data System (LI-RADS), a nonviable imaging response was 75% sensitive and 57% specific for CPN.

CONCLUSIONS

Radiation segmentectomy and multimodal therapy significantly improved CPN rates compared with TACE alone. A LI-RADS treatment response of nonviable did not confidently predict CPN.

Liver Venous Deprivation for Rapid Liver Hypertrophy Before Major Hepatectomy: A Case Report

Liver venous deprivation (LVD) is an emerging, minimally invasive strategy to induce rapid liver hypertrophy of the future liver remnant (FLR) before a major hepatectomy. LVD (aka "double vein embolization") entails same-session percutaneous embolization of the portal and hepatic veins of the planned liver resection. This report discusses LVD's utilization and technical challenges in managing a 49-year-old male with recurrent multifocal colorectal liver metastases (CRLM). The patient initially underwent neoadjuvant FOLFOX chemotherapy followed by a simultaneous laparoscopic sigmoid colectomy and liver surgery (microwave ablation of segment V and wedge resections of segment one and IVb), followed by completion of chemotherapy. The patient had an R0 resection with clear colon and liver surgical margins. Nine months after the initial surgery, the patient had a rise in tumor markers, and surveillance imaging demonstrated recurrence of liver metastases in segments I and V. LVD was performed by interventional radiology, which led to a 28% increase in FLR (segments II, III, and IV); initially measuring 464 cm3 before LVD and measuring 594 cm3 on post-procedure day 21. The patient underwent right hemi-hepatectomy and caudate resection on post-procedure day 29. The patient did not have any complications and was discharged on postoperative day 6. The patient remains disease-free with no evidence of recurrence at 12 months follow-up.

Large Bore Portal Vein Thrombectomy: An Inari FlowTriever Case Series

PURPOSE

Portal vein thrombus (PVT) can worsen portal hypertension and hepatic decompensation in patients with cirrhosis and impact liver transplant outcomes. This retrospective case series describes large bore mechanical thrombectomy of PVT with the Inari FlowTriever device during, or remotely after, transjugular intrahepatic portosystemic shunt (TIPS) placement.

MATERIALS AND METHODS

Ten patients with PVT were treated with large bore thrombectomy. All patients had underlying cirrhosis, complicated by portal hypertension with acute/subacute PVT. Thrombectomy was performed either with TIPS placement, or via a previously placed thrombosed shunt. Median time from TIPS placement to thrombectomy was 3 years.

RESULTS

Thrombectomy was technically successful in all patients with a majority achieving complete resolution of PVT in a single session. During mean follow-up of 13.3 months, all patients achieved complete resolution of PVT without recurrence.

CONCLUSION

Large bore mechanical thrombectomy together with TIPS is a feasible and effective treatment of acute/subacute PVT in cirrhotic patients with portal hypertension, often with complete resolution in a single session.

Utilization of κ-carrageenan as stabilizer and thickener of honey pineapple (Ananas comosus [L. Merr]) jam

Honey pineapple jam is an intermediate moisture food that often has low stability; hence it is not strong enough to hold the fruit tissue sugar in position during storage. Therefore, it is necessary to add hydrocolloid in fruit jam processing to increase stability and consistency, one of which is κ-carrageenan. The purpose of this study was to determine the effect of adding κ-carrageenan towards stability and preference for honey pineapple jam. The κ-carrageenan concentrations used were 0%, 0.5%, 1%, and 1.5% (w/w) of total ingredients. The ratio of honey pineapple pulp and sugar was 4:1 (w/w). The results showed that the addition of κ-carrageenan had a significant effect (p<0.05) on the hedonic evaluation of colour, smearing ability, and texture; moisture content, water activity (Aw), syneresis and texture (hardness, cohesiveness, and adhesiveness). The addition of κcarrageenan had no significant effect (p>0.05) on the hedonic evaluation (preference) of aroma and taste. Increasing the κ-carrageenan concentration can increase the hedonic value for colour and decrease the hedonic value for smearing ability and texture. Increasing the concentration of κ-carrageenan can also increase the value of hardness and cohesiveness but decrease water activity, syneresis, and adhesiveness. The addition of κcarrageenan 0.5% was more efficient in shortening the cooking time until 25%, inhibiting syneresis by 30%, and improving the colour of honey pineapple jam.

Portal Vein Thrombosis In Cirrhosis: Interventional Treatment Options

PURPOSE OF REVIEW

Portal vein thrombosis (PVT) is a frequent consequence of cirrhosis and its management is variable and controversial. Herein we highlight interventional treatment options and outcomes, together with mention of the physiology, presentation and imaging of PVT.

RECENT FINDINGS

Utilization of transjugular intrahepatic portosystemic shunt (TIPS) for acute and chronic PVT is expanding. In acute PVT, TIPS improves hepatopetal flow which promotes thrombus resorption and prevents rethrombosis. The TIPS also functions as a conduit for thrombectomy devices and allows for embolization of variceal shunts. Chronic PVT is a relative contraindication to liver transplant. Portal vein recanalization (PVR) TIPS restores flow in a previously occluded portal vein, allowing for a conventional end-to-end portal vein anastomosis at transplant. PVR TIPS is technically demanding and often requires percutaneous splenic vein access for portal venous recanalization. Selection of endovascular PVT treatment varies with the age (acute or chronic) and the extent of thrombus, along with presenting symptoms and transplant candidacy.

597 Counting on You to do The Count: An Unusual Case Report of a Delayed and Missed Gossypiboma Secondary to Swiss Cheese Model Failings

Introduction

Gossypiboma is a term describing a retained surgical swab which is a serious complication following any surgical intervention. The incidence of these cases is wholly under reported, partly due to medicolegal aspects, but also due to the misnomer of diagnosis. In this case, we discuss the multifactorial deficiencies which led to a significant morbidity in a patient who had remained asymptomatic for nine years since index surgery.

Case Presentation

A 40-year-old woman presented to the emergency department febrile with a one week history of abdominal pain, on a background of a one year history of chronic pain. The patient’s surgical history demonstrated an ovarian fibroid excision and a subtotal hysterectomy nine and six years ago, respectively. It was later noted the chronic abdominal pain had been previously investigated with positive findings on imaging and biopsy, however, she was lost to follow up. A year later, she presented with an acute abdomen and operative findings of a large abscess cavity, containing a retained swab, with small bowel fistulation were noted.

Conclusions

This reiterates the importance of surgical safety checklists, and often despite this there are many factors that can eventually lead to complete alignment of the holes in the Swiss Cheese leading to unfavourable outcomes. It is imperative to remain hypervigilant during checkpoints, particularly in emergencies where the unpredictability of the operation leads to human error. Gossypiboma remains a serious cause for morbidity and mortality, thus the potential for modified safety checklists or alternative methods for surgical counts.

Assessing the effects of manual dexterity and playing computer games on catheter-wire manipulation for inexperienced operators

AIM

To investigate the effect of playing computer games and manual dexterity on catheter-wire manipulation in a mechanical aortic model.

MATERIAL AND METHODS

Medical student volunteers filled in a preprocedure questionnaire assessing their exposure to computer games. Their manual dexterity was measured using a smartphone game. They were then shown a video clip demonstrating renal artery cannulation and were asked to reproduce this. All attempts were timed. Two-tailed Student's t-test was used to compare continuous data, while Fisher's exact test was used for categorical data.

RESULTS

Fifty students aged 18-22 years took part in the study. Forty-six completed the task at an average of 168 seconds (range 103-301 seconds). There was no significant difference in the dexterity score or time to cannulate the renal artery between male and female students. Students who played computer games for >10 hours per week had better dexterity scores than those who did not play computer games: 9.1 versus 10.2 seconds (p=0.0237). Four of 19 students who did not play computer games failed to complete the task, while all of those who played computer games regularly completed the task (p=0.0168).

CONCLUSION

Playing computer games is associated with better manual dexterity and ability to complete a basic interventional radiology task for novices.

Improving Diagnostic Efficiency in Children Aged 12-39 Months Referred for Autism Spectrum Disorder (ASD)

BACKGROUND: Early diagnosis and intervention for ASD is important. The increasing prevalence of ASD in Canada is challenging teams performing ASD diagnostic evaluations to keep pace with demand. In October 2013, the ASD clinic at our Pediatric Tertiary Care Centre (PTCC) faced a waitlist of more than twelve months for children under 39 months of age; it became necessary to engage in a quality improvement with the aim of looking for efficiencies with a focus of reducing our waitlist.

OBJECTIVES: To present a) two years of experience (Jan. 2014-Dec. 2015) using our diagnostic assessment model for evaluation of children aged 12-39 months referred for ASD evaluation to PTCC, and b) psychometric performance of RITA-T (Rapid Interactive Test for Autism in Toddlers-developed by Choueiri/Wagner – Boston).

DESIGN/METHODS: This quality improvement project incorporated evidence-based practice with process improvement methodology. Our team utilized a Plan-Do-Study-Act (PDSA) approach in the development of a ‘new’ ASD standardized diagnostic process. Our new model included: a) an initial mandatory parent education session followed one week later by b) a child visit using the face-to-face ‘level 2 screening tool’ (RITA-T) + completion of M-CHAT (questionnaire) followed in 7-10 days by c) an ASD diagnostic evaluation appointment, and finally 5-7 days after evaluation d) an “After ASD Diagnosis” parent group session.

RESULTS: We assessed a total of 173 patients (81% male, mean age 30.74±5.53 mo., interval 15.4-39.0 mo.). The diagnostic process was completed within a max 30-day cycle (previously a period &gt;4 months) and required less hours/child (12 vs. 20 hours – overall 40% net gain or 1384 hours). Waitlist was reduced to &lt;1 month (compared to &gt;12 mo. in Oct. 2013). A total of 143 children (82.7% of total cohort; 116 male/27 female) were diagnosed with ASD. The discriminative properties of RITA-T were calculated: Sensitivity: 0.99; Specificity 0.53; Positive Predictive Value 0.91; Negative Predictive Value: 0.94.

CONCLUSION: By following a combination of quality improvement methodology with evidence-based practice, we successfully reduced wait and cycle times at our PTCC for children aged 12-39 months referred for ASD diagnostic assessment. RITA-T showed very good discriminative properties and was instrumental in the overall process improvement. This sustainable diagnostic approach promoted practice innovation. Consequently, patients are now able to access critical community supports and resources in a timely manner.

Management of Acute Pulmonary Embolism: Consensus Statement for Indian Patients

Pulmonary embolism (PE) is an important cause of morbidity and mortality among hospitalized patients. Although the exact epidemiology of PE is not known in India, Some of the studies show that more frequently it is missed and not managed appropriately leading to significant cardiovascular morbidity and mortality. Justification and purpose: Indian guidelines for the diagnosis and treatment of acute PE are not yet formulated. The objective of this consensus statement is to propose a diagnostic and management approach for acute PE in India.

PROCESS

A working group of 15 experts in the management of acute PE (cardiologists, pulmonologist, haematologist, emergency specialist and intensivists). This consensus statement makes recommendations for diagnosis and management for PE based on literature review, including Indian data.

Percutaneous sclerotherapy of cystic lesions

With modern cross-sectional imaging techniques, cystic lesions are very common and usually incidental findings, especially if small. However, when cysts enlarge, become infected, bleed, or undergo torsion, they can be symptomatic, and percutaneous drainage can be effective in the management. When cysts recur after aspiration, which is often the case for hepatic and renal cysts, cyst sclerosis or surgical unroofing may be required. This article describes the indications for and technical aspects of percutaneous sclerotherapy of cystic lesions of multiple organ systems.

Simultaneous static and cine nonenhanced MR angiography using radial sampling and highly constrained back projection reconstruction

PURPOSE

To describe a pulse sequence for simultaneous static and cine nonenhanced magnetic resonance angiography (NEMRA) of the peripheral arteries.

METHODS

The peripheral arteries of 10 volunteers and 6 patients with peripheral arterial disease (PAD) were imaged with the proposed cine NEMRA sequence on a 1.5 Tesla (T) system. The impact of multi-shot imaging and highly constrained back projection (HYPR) reconstruction was examined. The propagation rate of signal along the length of the arterial tree in the cine nonenhanced MR angiograms was quantified.

RESULTS

The cine NEMRA sequence simultaneously provided a static MR angiogram showing vascular anatomy as well as a cine display of arterial pulse wave propagation along the entire length of the peripheral arteries. Multi-shot cine NEMRA improved temporal resolution and reduced image artifacts. HYPR reconstruction improved image quality when temporal reconstruction footprints shorter than 100 ms were used (P < 0.001). Pulse wave propagation within the arterial tree as displayed by cine NEMRA was slower in patients with PAD than in volunteers.

CONCLUSION

Simultaneous static and cine NEMRA of the peripheral arteries is feasible. Multi-shot acquisition and HYPR reconstruction can be used to improve arterial conspicuity and temporal resolution.

Management of Complicated Appendicitis in the Pediatric Population: When Surgery Doesn't Cut It

The management of complicated appendicitis in children has evolved significantly over the last century. What initially was a surgeon's dilemma is becoming the interventional radiologist's task because image-guided percutaneous drainage of abscesses from a ruptured appendix obviates the need for urgent surgery and allows for selective interval appendectomy at the surgeon's discretion (versus conservative nonoperative management in selected cases). This paradigm shift places the onus on the interventional radiologist to recognize when the procedure is emergently indicated and to be cognizant of the special needs of a pediatric patient.

Quiescent-inflow single-shot magnetic resonance angiography using a highly undersampled radial k-space trajectory

PURPOSE

We hypothesized that high undersampling factors could be used in conjunction with radial quiescent-inflow single-shot magnetic resonance angiography (MRA) to accelerate the data acquisition and enable multislice acquisitions.

METHODS

Seven subjects were imaged on a 1.5 T MRI system. For multislice quiescent-inflow single-shot MRA, the venous saturation radiofrequency pulse, in-plane saturation radiofrequency pulse, and quiescent interval were applied only once before the first slice.

RESULTS

The mean (standard deviation) measurements for the intra-arterial signal-to-noise ratio were as follows: Cartesian 1 slice-29.3 (5.5); radial 1 slice, 92 views-22.3 (3.6); radial 1 slice, 46 views-18.5 (2.0); radial 2 slices, 46 views-18.3 (3.2); and radial 3 slices, 32 views-21.7 (3.9), normalized for pixel size to 15.8. Horizontal striping was present with multislice radial quiescent-inflow single-shot MRA (especially with the three-slice acquisition) due to variable T1 relaxation between the concurrently acquired slices, but the image quality remained diagnostic. Vascular pathology in patients with peripheral arterial disease was well shown by all techniques.

CONCLUSION

Very high undersampling factors in excess of 18 have been demonstrated for nonenhanced MRA using a radial quiescent-inflow single-shot technique, enabling the acquisition of two to three slices per cardiac cycle. Scan time for a complete peripheral MRA could be shortened to 2 min or less.

Self-administration of misoprostol for termination of pregnancy: safety and efficacy

We conducted a retrospective study to determine the efficacy and safety of self-administration of vaginal misoprostol (following oral mifeprestone) for medical termination of pregnancy. This study revealed that self-administration was accepted by the majority of the patients (90%) and the success rate (98.4%) and duration of hospital stay was not altered significantly compared to our previous year's data, where women were administered vaginal misoprostol by the staff. Based on this study's results, we are of the opinion that this regimen not only demedicalises the problem but also decreases the workload for the medical staff.

Weekly paclitaxel (P) with concurrent external beam radiation (EBRT) and androgen deprivation therapy (ADT) in high-risk prostate cancer (PC) patients with or without prior prostatectomy (RP)

5122

Background: EBRT with ADT (4 mos to 2–3 yrs) is standard treatment for high risk PC. In this trial, we evaluated weekly P given concurrently with EBRT and ADT in high risk PC. Methods: For pts undergoing RP, high risk was defined as: pT3 and/or pN+, M0, and/or rising PSA (> 0.5) post RP. For pts not undergoing RP (i.e. locally advanced PC [LAPC]) high risk included: cT2b-4N0, N+, M0; bGS 8–10; bGS ≥ 7 + PSA ≥ 10 but ≤ 150; and/or PSA ≥ 20 but ≤ 150. Treatment included ADT (4 or 24 mos, preplanned based on clinical presentation), P (40, 50, or 60 mg/m2/wk) x 7 with EBRT, and whole pelvis EBRT 45 Gy with 19.8 Gy boost (total 64.8 Gy) to prostate bed in RP pts and 25.2 Gy boost (total 70.2 Gy) to prostate in LAPC pts. Results: Between October 1999 and December 2006, 59 pts (29 W, 28 AA) were enrolled (n = 29 LAPC, n = 30 RP); median age 67 yrs, median PSA at trial entry 5.9 (27.5 LAPC, 1.6 RP), median GS 8. Pts were enrolled at different weekly doses of P: 40 mg/m2 n = 10 pts; 50 mg/m2 n = 31 pts; 60 mg/m2 n = 18 pts. ADT for 4 mos was given in 29 pts and for 24 mos in 30 pts. At 40 mg/m2 67/70 (96%), 50 mg/m2 202/217 (93%), and 60 mg/m2 98/126 (78%) planned doses of P were given. There were no acute grade 4 toxicities. Most common grade 3 toxicities were diarrhea 15%, urinary urgency or incontinence 10%, tenesmus 5%, and leukopenia 3%. Median duration of f/u was 75.3 mos, OS 78%, biochemical progression 24/59 (41%) pts, clinical progression 11/59 (19%) pts. Time to biochemical progression was similar between RP vs. LAPC (p = 0.17), between ADT 4 mos vs. 24 mos (p = 0.61), and between AA vs. W (p = 0.54). Conclusions: This trial establishes the feasibility of tri-modality therapy with ADT, EBRT and weekly paclitaxel in high risk PC, both in RP pts and in LAPC pts with intact prostate glands. The maximum tolerated dose of paclitaxel is 50 mg/m2 /wk when given weekly with concurrent radiation to the pelvis and hormone ablation.

No significant financial relationships to disclose.

Wide excision and ulno-carpal arthrodesis for primary aggressive and recurrent giant cell tumours

Twenty-five patients underwent wide resection of the distal radial giant cell tumours (GCTs) followed by ulno-carpal arthrodesis. There were 15 male and ten female patients, with an average age of 21.5 years. Tumours included ten primary aggressive and 15 recurrent GCTs. Mean follow up was 2.4 years. Pain, swelling and reduced range of movement (ROM) were noted. Average time to fusion was 7.6 months. Five patients had persistent pain in the proximal forearm. Grip strength was 65% compared to the uninvolved side. Two patients had superficial wound infection, two underwent additional bone grafting and three implant removals due to hardware prominence were carried out. There was no evidence of carpal instability or arthritis on clinical or radiological examination at the time of final follow up. Fusion of the carpus to the ulna is a simple method of producing a painless stable wrist, though at the expense of mobility. The procedure allows wide resection with a lower rate of recurrence. Pain in the proximal forearm seems to persist for 3 to 4 months only to improve at subsequent follow up. The procedure provides a valid option for the management of primary aggressive and recurrent GCTs of distal radius.