1
|
Wlodzimierz P, Rabanal FA, Burns R, Naish M, Primetis E, Scott A, Mandáková T, Gorringe N, Tock AJ, Holland D, Fritschi K, Habring A, Lanz C, Patel C, Schlegel T, Collenberg M, Mielke M, Nordborg M, Roux F, Shirsekar G, Alonso-Blanco C, Lysak MA, Novikova PY, Bousios A, Weigel D, Henderson IR. Cycles of satellite and transposon evolution in Arabidopsis centromeres. Nature 2023:10.1038/s41586-023-06062-z. [PMID: 37198485 DOI: 10.1038/s41586-023-06062-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 04/06/2023] [Indexed: 05/19/2023]
Abstract
Centromeres are critical for cell division, loading CENH3 or CENPA histone variant nucleosomes, directing kinetochore formation and allowing chromosome segregation1,2. Despite their conserved function, centromere size and structure are diverse across species. To understand this centromere paradox3,4, it is necessary to know how centromeric diversity is generated and whether it reflects ancient trans-species variation or, instead, rapid post-speciation divergence. To address these questions, we assembled 346 centromeres from 66 Arabidopsis thaliana and 2 Arabidopsis lyrata accessions, which exhibited a remarkable degree of intra- and inter-species diversity. A. thaliana centromere repeat arrays are embedded in linkage blocks, despite ongoing internal satellite turnover, consistent with roles for unidirectional gene conversion or unequal crossover between sister chromatids in sequence diversification. Additionally, centrophilic ATHILA transposons have recently invaded the satellite arrays. To counter ATHILA invasion, chromosome-specific bursts of satellite homogenization generate higher-order repeats and purge transposons, in line with cycles of repeat evolution. Centromeric sequence changes are even more extreme in comparison between A. thaliana and A. lyrata. Together, our findings identify rapid cycles of transposon invasion and purging through satellite homogenization, which drive centromere evolution and ultimately contribute to speciation.
Collapse
Affiliation(s)
- Piotr Wlodzimierz
- Department of Plant Sciences, University of Cambridge, Cambridge, UK
| | - Fernando A Rabanal
- Department of Molecular Biology, Max Planck Institute for Biology Tübingen, Tübingen, Germany
| | - Robin Burns
- Department of Plant Sciences, University of Cambridge, Cambridge, UK
| | - Matthew Naish
- Department of Plant Sciences, University of Cambridge, Cambridge, UK
| | - Elias Primetis
- School of Life Sciences, University of Sussex, Brighton, UK
| | - Alison Scott
- Department of Chromosome Biology, Max Planck Institute for Plant Breeding Research, Cologne, Germany
| | - Terezie Mandáková
- Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Nicola Gorringe
- Department of Plant Sciences, University of Cambridge, Cambridge, UK
| | - Andrew J Tock
- Department of Plant Sciences, University of Cambridge, Cambridge, UK
| | - Daniel Holland
- Department of Plant Sciences, University of Cambridge, Cambridge, UK
| | - Katrin Fritschi
- Department of Molecular Biology, Max Planck Institute for Biology Tübingen, Tübingen, Germany
| | - Anette Habring
- Department of Molecular Biology, Max Planck Institute for Biology Tübingen, Tübingen, Germany
| | - Christa Lanz
- Department of Molecular Biology, Max Planck Institute for Biology Tübingen, Tübingen, Germany
| | - Christie Patel
- Department of Plant Sciences, University of Cambridge, Cambridge, UK
| | - Theresa Schlegel
- Department of Molecular Biology, Max Planck Institute for Biology Tübingen, Tübingen, Germany
| | - Maximilian Collenberg
- Department of Molecular Biology, Max Planck Institute for Biology Tübingen, Tübingen, Germany
| | - Miriam Mielke
- Department of Molecular Biology, Max Planck Institute for Biology Tübingen, Tübingen, Germany
| | - Magnus Nordborg
- Gregor Mendel Institute, Vienna, Austrian Academy of Sciences, Vienna BioCenter, Vienna, Austria
| | - Fabrice Roux
- LIPME, INRAE, CNRS, Université de Toulouse, Castanet-Tolosan, France
| | - Gautam Shirsekar
- Department of Molecular Biology, Max Planck Institute for Biology Tübingen, Tübingen, Germany
| | - Carlos Alonso-Blanco
- Departamento de Genética Molecular de Plantas, Centro Nacional de Biotecnología, Consejo Superior de Investigaciones Científicas, Madrid, Spain
| | - Martin A Lysak
- Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Polina Y Novikova
- Department of Chromosome Biology, Max Planck Institute for Plant Breeding Research, Cologne, Germany
| | | | - Detlef Weigel
- Department of Molecular Biology, Max Planck Institute for Biology Tübingen, Tübingen, Germany.
| | - Ian R Henderson
- Department of Plant Sciences, University of Cambridge, Cambridge, UK.
| |
Collapse
|
2
|
Primetis E, Drakopoulos D, Sieron D, Meusburger H, Szyluk K, Niemiec P, Obmann VC, Peters AA, Huber AT, Ebner L, Delimpasis G, Christe A. Knee Diameter and Cross-Sectional Area as Biomarkers for Cartilage Knee Degeneration on Magnetic Resonance Images. Medicina (Kaunas) 2022; 59:medicina59010027. [PMID: 36676651 PMCID: PMC9865157 DOI: 10.3390/medicina59010027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 12/16/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022]
Abstract
Background and Objectives: Osteoarthritis (OA) of the knee is a degenerative disorder characterized by damage to the joint cartilage, pain, swelling, and walking disability. The purpose of this study was to assess whether demographic and radiologic parameters (knee diameters and knee cross-sectional area from magnetic resonance (MR) images) could be used as surrogate biomarkers for the prediction of OA. Materials and Methods: The knee diameters and cross-sectional areas of 481 patients were measured on knee MR images, and the corresponding demographic parameters were extracted from the patients' clinical records. The images were graded based on the modified Outerbridge arthroscopic classification that was used as ground truth. Receiver-operating characteristic (ROC) analysis was performed on the collected data. Results: ROC analysis established that age was the most accurate predictor of severe knee cartilage degeneration (corresponding to Outerbridge grades 3 and 4) with an area under the curve (AUC) of the specificity-sensitivity plot of 0.865 ± 0.02. An age over 41 years was associated with a sensitivity and specificity for severe degeneration of 82.8% (CI: 77.5-87.3%), and 76.4% (CI: 70.4-81.6%), respectively. The second-best degeneration predictor was the normalized knee cross-sectional area, with an AUC of 0.767 ± 0.04), followed by BMI (AUC = 0.739 ± 0.02), and normalized knee maximal diameter (AUC = 0.724 ± 0.05), meaning that knee degeneration increases with increasing knee diameter. Conclusions: Age is the best predictor of knee damage progression in OA and can be used as surrogate marker for knee degeneration. Knee diameters and cross-sectional area also correlate with the extent of cartilage lesions. Though less-accurate predictors of damage progression than age, they have predictive value and are therefore easily available surrogate markers of OA that can be used also by general practitioners and orthopedic surgeons.
Collapse
Affiliation(s)
- Elias Primetis
- Department of Radiology SLS, Inselgroup, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland
| | - Dionysios Drakopoulos
- Department of Radiology SLS, Inselgroup, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland
| | - Dominik Sieron
- Department of Radiology SLS, Inselgroup, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland
| | - Hugo Meusburger
- Department of Radiology SLS, Inselgroup, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland
| | - Karol Szyluk
- Department of Physiotherapy, Faculty of Health Sciences in Katowice, Medical University of Silesia in Katowice, 40-752 Katowice, Poland
- District Hospital of Orthopaedics and Trauma Surgery, Bytomska 62 St., 41-940 Piekary Slaskie, Poland
| | - Paweł Niemiec
- Department of Biochemistry and Medical Genetics, Faculty of Health Sciences in Katowice, Medical University of Silesia in Katowice, 40-752 Katowice, Poland
| | - Verena C. Obmann
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Alan A. Peters
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Adrian T. Huber
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Lukas Ebner
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Georgios Delimpasis
- Department of Radiology SLS, Inselgroup, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland
| | - Andreas Christe
- Department of Radiology SLS, Inselgroup, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Correspondence:
| |
Collapse
|
3
|
Kordeni K, Chardalias L, Pantiora E, Massaras D, Papadopoulos K, Primetis E, Kontis E, Fragulidis G. Retroperitoneal ganglioneuroma presenting as lower back pain. J Surg Case Rep 2022; 2022:rjac082. [PMID: 35444793 PMCID: PMC9015710 DOI: 10.1093/jscr/rjac082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/18/2022] [Indexed: 11/25/2022] Open
Abstract
Retroperitoneal ganglioneuroma (RGN) is a rare benign tumor that arises from the retroperitoneal sympathetic ganglia composed of mature Schwann cells, ganglion cells and nerve fibers. These tumors can occur anywhere along the paravertebral sympathetic plexus and occasionally from adrenal medulla. Although they grow in excessive size, they may cause compression to adjacent organ or structures thus giving rise to symptoms. Resecting RGN’s is a challenging endeavor, as they tend to encase neighboring vessels to their site of origin. The reported case is a 43-year-old male who presented with lumbar pain that increased progressively in intensity over the last 6 months. Preoperative investigations revealed a large tumor with encasement of the origins of the superior mesenteric artery and bilateral renal arteries. The tumor was completely resected and the final pathology confirmed the diagnosis of RGN.
Collapse
Affiliation(s)
- Kleoniki Kordeni
- 2nd Department of Surgery, Aretaieion Hospital, School of Medicine National and Kapodistrian University of Athens, Athens, Greece
| | - Leonidas Chardalias
- 2nd Department of Surgery, Aretaieion Hospital, School of Medicine National and Kapodistrian University of Athens, Athens, Greece
| | - Eirini Pantiora
- 2nd Department of Surgery, Aretaieion Hospital, School of Medicine National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitris Massaras
- 2nd Department of Surgery, Aretaieion Hospital, School of Medicine National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Papadopoulos
- Department of Pathology, Aretaieion Hospital, School of Medicine National, Kapodistrian University of Athens, Athens, Greece
| | - Elias Primetis
- 1st Department of Radiology, Aretaieion Hospital, School of Medicine National, Kapodistrian University of Athens, Athens, Greece
| | - Elissaios Kontis
- 2nd Department of Surgery, Aretaieion Hospital, School of Medicine National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Fragulidis
- 2nd Department of Surgery, Aretaieion Hospital, School of Medicine National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
4
|
Misura T, Drakopoulos D, Mitrakovic M, Loennfors T, Primetis E, Hoppe H, Obmann VC, Huber AT, Ebner L, Christe A. Avoiding the Intercostal Arteries in Percutaneous Thoracic Interventions. J Vasc Interv Radiol 2022; 33:416-419.e2. [DOI: 10.1016/j.jvir.2021.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 11/26/2022] Open
|
5
|
Massaras D, Kontis E, Stamatis K, Zampeli E, Myoteri D, Primetis E, Pantiora E, Fragulidis G. Primary leiomyosarcoma of the colon with synchronous liver metastasis. Rare Tumors 2022; 14:20363613221080549. [PMID: 35360880 PMCID: PMC8961372 DOI: 10.1177/20363613221080549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 01/27/2022] [Indexed: 12/02/2022] Open
Affiliation(s)
- Dimitrios Massaras
- 2ndDepartment of Surgery, National and Kapodistrian University of Athens, Aretaieio Hospital, Athens, Greece
| | - Elissaios Kontis
- 2ndDepartment of Surgery, National and Kapodistrian University of Athens, Aretaieio Hospital, Athens, Greece
| | - Konstantinos Stamatis
- 2ndDepartment of Surgery, National and Kapodistrian University of Athens, Aretaieio Hospital, Athens, Greece
| | - Evanthia Zampeli
- Department of Gastroenterology Alexandra General Hospital, Athens Greece
| | - Despoina Myoteri
- Department of Pathology, National and Kapodistrian University of Athens, Aretaieio Hospital, Athens, Greece
| | | | - Eirini Pantiora
- 2ndDepartment of Surgery, National and Kapodistrian University of Athens, Aretaieio Hospital, Athens, Greece
| | - Georgios Fragulidis
- 2ndDepartment of Surgery, National and Kapodistrian University of Athens, Aretaieio Hospital, Athens, Greece
| |
Collapse
|
6
|
Primetis E, Chavlis S, Pavlidis P. Evolutionary models of amino acid substitutions based on the tertiary structure of their neighborhoods. Proteins 2021; 89:1565-1576. [PMID: 34278605 DOI: 10.1002/prot.26178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 05/27/2021] [Accepted: 07/11/2021] [Indexed: 11/10/2022]
Abstract
Intra-protein residual vicinities depend on the involved amino acids. Energetically favorable vicinities (or interactions) have been preserved during evolution, while unfavorable vicinities have been eliminated. We describe, statistically, the interactions between amino acids using resolved protein structures. Based on the frequency of amino acid interactions, we have devised an amino acid substitution model that implements the following idea: amino acids that have similar neighbors in the protein tertiary structure can replace each other, while substitution is more difficult between amino acids that prefer different spatial neighbors. Using known tertiary structures for α-helical membrane (HM) proteins, we build evolutionary substitution matrices. We constructed maximum likelihood phylogenies using our amino acid substitution matrices and compared them to widely-used methods. Our results suggest that amino acid substitutions are associated with the spatial neighborhoods of amino acid residuals, providing, therefore, insights into the amino acid substitution process.
Collapse
Affiliation(s)
- Elias Primetis
- Department of Biology, University of Crete, Heraklion, Greece.,Institute of Molecular Biology and Biotechnology, Foundation for Research and Technology, Hellas, Heraklion, Greece
| | - Spyridon Chavlis
- Institute of Molecular Biology and Biotechnology, Foundation for Research and Technology, Hellas, Heraklion, Greece
| | - Pavlos Pavlidis
- Institute of Computer Science, Foundation for Research and Technology, Hellas, Heraklion, Greece
| |
Collapse
|
7
|
Fontanellaz M, Ebner L, Huber A, Peters A, Löbelenz L, Hourscht C, Klaus J, Munz J, Ruder T, Drakopoulos D, Sieron D, Primetis E, Heverhagen JT, Mougiakakou S, Christe A. A Deep-Learning Diagnostic Support System for the Detection of COVID-19 Using Chest Radiographs: A Multireader Validation Study. Invest Radiol 2021; 56:348-356. [PMID: 33259441 DOI: 10.1097/rli.0000000000000748] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
MATERIALS AND METHODS Five publicly available databases comprising normal CXR, confirmed COVID-19 pneumonia cases, and other pneumonias were used. After the harmonization of the data, the training set included 7966 normal cases, 5451 with other pneumonia, and 258 CXRs with COVID-19 pneumonia, whereas in the testing data set, each category was represented by 100 cases. Eleven blinded radiologists with various levels of expertise independently read the testing data set. The data were analyzed separately with the newly proposed artificial intelligence-based system and by consultant radiologists and residents, with respect to positive predictive value (PPV), sensitivity, and F-score (harmonic mean for PPV and sensitivity). The χ2 test was used to compare the sensitivity, specificity, accuracy, PPV, and F-scores of the readers and the system. RESULTS The proposed system achieved higher overall diagnostic accuracy (94.3%) than the radiologists (61.4% ± 5.3%). The radiologists reached average sensitivities for normal CXR, other type of pneumonia, and COVID-19 pneumonia of 85.0% ± 12.8%, 60.1% ± 12.2%, and 53.2% ± 11.2%, respectively, which were significantly lower than the results achieved by the algorithm (98.0%, 88.0%, and 97.0%; P < 0.00032). The mean PPVs for all 11 radiologists for the 3 categories were 82.4%, 59.0%, and 59.0% for the healthy, other pneumonia, and COVID-19 pneumonia, respectively, resulting in an F-score of 65.5% ± 12.4%, which was significantly lower than the F-score of the algorithm (94.3% ± 2.0%, P < 0.00001). When other pneumonia and COVID-19 pneumonia cases were pooled, the proposed system reached an accuracy of 95.7% for any pathology and the radiologists, 88.8%. The overall accuracy of consultants did not vary significantly compared with residents (65.0% ± 5.8% vs 67.4% ± 4.2%); however, consultants detected significantly more COVID-19 pneumonia cases (P = 0.008) and less healthy cases (P < 0.00001). CONCLUSIONS The system showed robust accuracy for COVID-19 pneumonia detection on CXR and surpassed radiologists at various training levels.
Collapse
Affiliation(s)
| | - Lukas Ebner
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital
| | - Adrian Huber
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital
| | - Alan Peters
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital
| | - Laura Löbelenz
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital
| | - Cynthia Hourscht
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital
| | - Jeremias Klaus
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital
| | - Jaro Munz
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital
| | - Thomas Ruder
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital
| | - Dionysios Drakopoulos
- Department of Radiology, Division City and County Hospitals, Inselgroup, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dominik Sieron
- Department of Radiology, Division City and County Hospitals, Inselgroup, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Elias Primetis
- Department of Radiology, Division City and County Hospitals, Inselgroup, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | | |
Collapse
|
8
|
Muyle A, Seymour D, Darzentas N, Primetis E, Gaut BS, Bousios A. Gene capture by transposable elements leads to epigenetic conflict in maize. Mol Plant 2021; 14:237-252. [PMID: 33171302 DOI: 10.1016/j.molp.2020.11.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/15/2020] [Accepted: 11/05/2020] [Indexed: 06/11/2023]
Abstract
Transposable elements (TEs) regularly capture fragments of genes. When the host silences these TEs, siRNAs homologous to the captured regions may also target the genes. This epigenetic crosstalk establishes an intragenomic conflict: silencing the TEs has the cost of silencing the genes. If genes are important, however, natural selection may maintain function by moderating the silencing response, which may also advantage the TEs. In this study, we examined this model by focusing on Helitrons, Pack-MULEs, and Sirevirus LTR retrotransposons in the maize genome. We documented 1263 TEs containing exon fragments from 1629 donor genes. Consistent with epigenetic conflict, donor genes mapped more siRNAs and were more methylated than genes with no evidence of capture. However, these patterns differed between syntelog versus translocated donor genes. Syntelogs appeared to maintain function, as measured by gene expression, consistent with moderation of silencing for functionally important genes. Epigenetic marks did not spread beyond their captured regions and 24nt crosstalk siRNAs were linked with CHH methylation. Translocated genes, in contrast, bore the signature of silencing. They were highly methylated and less expressed, but also overrepresented among donor genes and located away from chromosomal arms, which suggests a link between capture and gene movement. Splitting genes into potential functional categories based on evolutionary constraint supported the synteny-based findings. TE families captured genes in different ways, but the evidence for their advantage was generally less obvious; nevertheless, TEs with captured fragments were older, mapped fewer siRNAs, and were slightly less methylated than TEs without captured fragments. Collectively, our results argue that TE capture triggers an intragenomic conflict that may not affect the function of important genes but may lead to the pseudogenization of less-constrained genes.
Collapse
Affiliation(s)
- Aline Muyle
- Department of Ecology and Evolutionary Biology, UC Irvine, Irvine, CA 92697, USA
| | - Danelle Seymour
- Department of Ecology and Evolutionary Biology, UC Irvine, Irvine, CA 92697, USA; Department of Botany and Plant Sciences, UC Riverside, Riverside, CA 92521, USA
| | - Nikos Darzentas
- Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Elias Primetis
- School of Life Sciences, University of Sussex, Brighton, UK
| | - Brandon S Gaut
- Department of Ecology and Evolutionary Biology, UC Irvine, Irvine, CA 92697, USA.
| | | |
Collapse
|
9
|
Fragulidis GP, Pantiora EV, Kontis EA, Primetis E, Polydorou A, Karvouni E, Polymeneas G. Biliary Mucinous Cystic Neoplasm of the Liver with Ovarian Stroma and Elevated Serum and Cystic Fluid Cancer Antigen 19-9 Levels. Cureus 2017; 9:e1863. [PMID: 29375949 PMCID: PMC5773268 DOI: 10.7759/cureus.1863] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Biliary mucinous cystic neoplasms of the liver are rare cystic tumors comprising less than 5% of the liver cystic neoplasms. These tumors demonstrate a female predominance and entail a risk of malignant transformation. We present a 56-year-old female patient with a multiloculated liver cystic lesion measuring 22 cm who underwent a cystectomy with en bloc resection of the liver segments II, III, and cholecystectomy. Serum cancer antigen 19.9 was 4,122.00 U/ml, supporting the diagnosis of a biliary cystic tumor. The cytology of the cystic fluid was negative for malignancy and intracystic fluid cancer antigen 19.9 level was measured over 12,000.00 U/l. The patient is free of recurrence at one-year follow up. Although a rare entity, the biliary mucinous cystic neoplasms should be considered in the differential diagnosis in the patients with liver cystic tumors. The appropriate management with complete surgical resection with negative margins is recommended given the risk of recurrence and malignant transformation.
Collapse
Affiliation(s)
- Georgios P Fragulidis
- 2nd Department of Surgery, ARETAIEIO Hospital, National and Kapodistrian University of Athens School of Medicine
| | - Eirini V Pantiora
- 2nd Department of Surgery, ARETAIEIO Hospital, National and Kapodistrian University of Athens School of Medicine
| | - Elissaios A Kontis
- 2nd Department of Surgery, ARETAIEIO Hospital, National and Kapodistrian University of Athens School of Medicine
| | - Elias Primetis
- 1st Department of Radiology, ARETAIEIO Hospital, National and Kapodistrian University of Athens School of Medicine
| | - Andreas Polydorou
- 2nd Department of Surgery, ARETAIEIO Hospital, National and Kapodistrian University of Athens School of Medicine
| | - Eleni Karvouni
- Department of Pathology, ARETAIEIO Hospital, National and Kapodistrian University of Athens School of Medicine
| | - George Polymeneas
- 2nd Department of Surgery, ARETAIEIO Hospital, National and Kapodistrian University of Athens School of Medicine
| |
Collapse
|
10
|
Fragulidis G, Pantiora E, Michalaki V, Kontis E, Primetis E, Vezakis A, Polydorou A. Immune-related intestinal pseudo-obstruction associated with nivolumab treatment in a lung cancer patient. J Oncol Pharm Pract 2017; 25:487-491. [PMID: 29067858 DOI: 10.1177/1078155217738325] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Immune checkpoint inhibition therapy using targeted monoclonal antibodies is a new therapeutic approach with significant survival benefit for patients with several cancer types. However, their use can be associated with unique immune-related adverse effects as a consequence of impaired self-tolerance due to loss of T-cell inhibition via a nonselective activation of the immune system. Nivolumab is an anti-PD-1 immune checkpoint inhibitor that was recently developed for cancer immunotherapy with remarkable responses in nonsmall cell lung cancer patients. We present a 62-year-old Caucasian male with recurrent lung adenocarcinoma and currently under third-line therapy with nivolumab, who was admitted in our hospital with abdominal distension. Radiologic findings were consistent with small bowel ileus. After four days of conservative treatment, the patient underwent exploratory laparotomy where no cause of ileus was discovered. Postoperative the ileus persisted and considering that an adverse effect of the immune checkpoint inhibition therapy occurred, the patient received high-dose prednisone resulting in gradual improvement of symptoms. Immune checkpoint inhibitors may induce adverse effects to unaffected organ systems and tissues including the skin, gastrointestinal, hepatic, pulmonary, and endocrine system. The mainstay treatment consists of immunosuppression with corticosteroids in the majority of cases. As the clinical use of immune checkpoint inhibitors is expanding rapidly, there is an emergence of unique immune-related adverse effects in a growing patient population. Gaining early awareness is essential in these patients in order to ensure prompt diagnosis and management.
Collapse
Affiliation(s)
- Georgios Fragulidis
- 1 2nd Dept. of Surgery, "Aretaieio" Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Eirini Pantiora
- 1 2nd Dept. of Surgery, "Aretaieio" Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Vasiliki Michalaki
- 2 Dept. of Oncology, "Aretaieio" Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Elissaios Kontis
- 1 2nd Dept. of Surgery, "Aretaieio" Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Elias Primetis
- 3 1st Dept. of Radiology, "Aretaieio" Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Antonios Vezakis
- 1 2nd Dept. of Surgery, "Aretaieio" Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Andreas Polydorou
- 1 2nd Dept. of Surgery, "Aretaieio" Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| |
Collapse
|
11
|
Pantiora EV, Kontis EA, Michalaki V, Primetis E, Vezakis A, Polydorou A, Fragulidis GP. Granuloma Mimicking Local Recurrence on PET/CT after Liver Resection of Colorectal Liver Metastasis: A Case Report. Cureus 2016; 8:e717. [PMID: 27625903 PMCID: PMC5010375 DOI: 10.7759/cureus.717] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Positron emission tomography–computed tomography (PET/CT) improves the diagnostic interpretation of fluorine-18 fluorodeoxyglucose (18F-FDG ) PET and CT in oncologic patients and has an impact on both diagnostic and therapeutic aspects of patient management. However, false positive findings from the PET/CT imaging should be taken into consideration as they mislead physicians into improper therapeutic actions. We present a 48-year-old female patient with a history of left colectomy for colorectal cancer and subsequent liver metastasectomy. After one year of follow-up, she presented with a highly suspicious lesion in the liver, which was confirmed on PET/CT as a metastatic liver tumor. Consequently, the patient underwent surgical excision of the tumor, and the definitive histological diagnosis showed a granulomatous tissue with giant cells and foreign body tissue reaction. Based on this report, we briefly review the dangerous pitfalls from radiological and PET/CT imaging concerning the preoperative diagnostic workup examination, as they may significantly alter the treatment plan in oncologic patients.
Collapse
Affiliation(s)
- Eirini V Pantiora
- 2nd Department of Surgery, ARETAIEIO Hospital, National and Kapodistrian University of Athens School of Medicine
| | - Elissaios A Kontis
- 2nd Department of Surgery, ARETAIEIO Hospital, National and Kapodistrian University of Athens School of Medicine
| | - Vasiliki Michalaki
- Department of Oncology, ARETAIEIO Hospital, National and Kapodistrian University of Athens School of Medicine
| | - Elias Primetis
- 1st Department of Radiology, ARETAIEIO Hospital, National and Kapodistrian University of Athens School of Medicine
| | - Antonios Vezakis
- 2nd Department of Surgery, ARETAIEIO Hospital, National and Kapodistrian University of Athens School of Medicine
| | - Andreas Polydorou
- 2nd Department of Surgery, ARETAIEIO Hospital, National and Kapodistrian University of Athens School of Medicine
| | - Georgios P Fragulidis
- 2nd Department of Surgery, ARETAIEIO Hospital, National and Kapodistrian University of Athens School of Medicine
| |
Collapse
|
12
|
Fragulidis GP, Chondrogiannis K, Vezakis A, Melemeni A, Kondi-Pafiti A, Primetis E, Polydorou A, Voros DC. Neuroendocrine differentiation in embryonal type hepatoblastoma. Hepatol Res 2013; 43:320-6. [PMID: 23437913 DOI: 10.1111/j.1872-034x.2012.01070.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Hepatoblastoma, a malignant tumor which arises occasionally in older children but very rarely in adults, exhibits divergent differentiation with embryonal cells, fetal hepatocytes and immature elements. This report describes an embryonal type hepatoblastoma with neuroendocrine differentiation in a 16-year-old patient, which was diagnosed postoperatively. Clinical and radiologic work-up failed to reveal a primary gastrointestinal malignancy and no primary lesions were detected in any other organ. This feature of hepatoblastoma is considered to be a multidirectional differentiation of the small epithelial or stem cells of the liver. At 2-year follow up, the patient remains symptom-free, with normal laboratory and diagnostic imaging studies, and no recurrent or metastatic disease identified.
Collapse
Affiliation(s)
- Georgios P Fragulidis
- 2nd Department of Surgery 1st Department of Anesthesia Department of Pathology Department of Radiology, Aretaieio Hospital, Medical School, University of Athens, Athens, Greece
| | | | | | | | | | | | | | | |
Collapse
|
13
|
Chatziioannou A, Gargas D, Malagari K, Kornezos I, Ioannidis I, Primetis E, Moschouris H, Gouliamos A, Mourikis D. Transcatheter arterial embolization as therapy of renal angiomyolipomas: the evolution in 15 years of experience. Eur J Radiol 2011; 81:2308-12. [PMID: 21708442 DOI: 10.1016/j.ejrad.2011.06.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Accepted: 06/01/2011] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This study aims at presenting the evolution of the embolization technique in treating renal angiomyolipomas (AMLs) either diagnosed in patients with acute bleeding or discovered accidentally. METHODS Ten patients with renal AMLs have been through thirteen selective transcatheter arterial embolizations for 15 years. Two patients had tuberous sclerosis complex (TSC) with bilateral tumors and were embolized twice. Four embolic materials were employed: PVA particles, Gianturco coils, microspheres and microcoils. Catheterization was achieved by means of 5F Cobra 2 catheters and coaxial microcatheter systems. RESULTS On an emergency basis, embolization was a first-line treatment. In one case, surgery was necessary; in two patients, a second embolization was performed. When treatment was preventive, a single embolization proved to be sufficient, as well. There was no significant deterioration of the serum creatinine levels in the post-embolization period. CONCLUSION Selective arterial embolization is a rather safe and effective technique to treat AMLs both urgently and preventively. Different embolic materials can be employed. Microspheres and microcatheters stand for new promising materials.
Collapse
Affiliation(s)
- A Chatziioannou
- University of Athens, Aretaieion Hospital, Radiology Department, Greece
| | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Papacharalampous X, Primetis E, Dalakidis A, Beck A, Mundinger A, Manusidis D, Gouliamos A. Diagnostische Wertigkeit von MRT bei Schultergelenkerkrankungen. Klinische und operative Korrelation. ROFO-FORTSCHR RONTG 2011. [DOI: 10.1055/s-0031-1279457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
15
|
Primetis E, Koureas A, Dalakidis A, Prantzos T, Palialexis K, Athanasios G. Congenital bronchial atresia with a calcified mucocele. Respiration 2011; 81:511-2. [PMID: 21447937 DOI: 10.1159/000324270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Elias Primetis
- Radiology Department, Aretaieio Hospital, University of Athens, Athens, Greece
| | | | | | | | | | | |
Collapse
|
16
|
Primetis E, Dalakidis A, Papacharalampous X, Skiadas V, Vlahos L, Gouliamos A. Extensive tumoral calcinosis in a patient with systemic sclerosis. Am J Orthop (Belle Mead NJ) 2010; 39:E108-E110. [PMID: 21290016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Tumoral calcinosis, a rare disease manifesting with periarticular, calcified masses in soft tissues, can be either primary or secondary to a disease, such as systemic sclerosis. In the case reported here, a patient diagnosed with systemic sclerosis presented with hard calcified masses that involved the shoulders and hips.
Collapse
Affiliation(s)
- Elias Primetis
- Radiology, Aretaieio Hospital, University of Athens, Athens, Greece
| | | | | | | | | | | |
Collapse
|
17
|
Primetis E, Kochilas X, Papacharalampous G, Nikolopoulos T. Bilateral Total Occlusion of the External Ear Canal in a Breath-Holder Diver: An Unusual Case. Skull Base 2009. [DOI: 10.1055/s-2009-1224416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
18
|
Kochilas X, Primetis E, Palialexis C, Nikolopoulos T. Ethmoid Sinus Giant Adenocarcinoma Recurrence Invading the Frontal Cranial Fossa: Should We Operate? Skull Base 2009. [DOI: 10.1055/s-2009-1224466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
19
|
Primetis E, Kochilas X, Vamvakidis T, Nikolopoulos T. Pulsatile Tinnitus: A Good Reason for Thorough Ear, Nose, Throat Investigation. Skull Base 2009. [DOI: 10.1055/s-2009-1224494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
20
|
Kochilas X, Primetis E, Gargas D, Crowther J. Giant, Deep Parotid Lobe Tumor: A Challenging Surgical Case. Skull Base 2009. [DOI: 10.1055/s-2009-1224491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
21
|
Katsavrias E, Primetis E, Karandreas N. Iliopsoas: A new electromyographic technique and normal motor unit action potential values. Clin Neurophysiol 2005; 116:2528-32. [PMID: 16214405 DOI: 10.1016/j.clinph.2005.07.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2004] [Revised: 06/24/2005] [Accepted: 07/02/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To describe a reliable technique of needle electrode examination and present the normal values of motor unit action potential (MUAP) parameters in iliopsoas muscle. METHODS Thirty-one normal subjects underwent quantitative electromyographic (QEMG) examination of the iliopsoas muscle, following an ultrasonographically confirmed technique of needle electrode insertion and sampling. The leg under examination was flexed, abducted and externally rotated at the hip joint and also flexed at the knee joint. A slight flexion at the hip joint was used to uncover iliopsoas from the overlying sartorius. This provides enough space at the inguinal region between the sartorius and the femoral neurovascular bundle. Mean and outlier values of MUAP parameters and polyphasia were calculated. RESULTS Our technique was easy to perform and secure in sampling iliopsoas. The mean +/- SD values for MUAP duration, amplitude, area, area to amplitude ratio, phases and turns were 11.5 +/- 1.35 ms, 419 +/- 71.5 microV, 633 +/- 142.7 microV ms, 1.57 +/- 0.25, 3.1 +/- 0.32, and 2.9 +/- 0.44, respectively. Lower and upper outlier limits for duration, amplitude, area and area to amplitude ratio were 3.6/20.7 ms, 150/930 microV, 100/1567 microV ms, and 0.35/3.07. Mean polyphasia was 12.6% (range 0-30%). CONCLUSIONS The suggested EMG technique helped to distinguish iliopsoas from sartorius and at the same time increased the accessibility of its anterior surface. Normal values and outlier limits of the MUAP parameters of iliopsoas have been quantitatively established. SIGNIFICANCE This new technique and the normal MUAP values might prove helpful for the examination of iliopsoas, important in the assessment of many neuropathic and, especially, myopathic processes.
Collapse
Affiliation(s)
- Evangelos Katsavrias
- EMG Laboratory, Neurology Department, Aeginition Hospital, University of Athens, Greece
| | | | | |
Collapse
|
22
|
Papacharalampous X, Patsouris E, Mundinger A, Beck A, Kouloulias V, Primetis E, Koureas A, Vlahos L. The effect of contrast media on the synovial membrane. Eur J Radiol 2005; 55:426-30. [PMID: 16129252 DOI: 10.1016/j.ejrad.2004.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2004] [Revised: 12/13/2004] [Accepted: 12/15/2004] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To examine the effect of intra-articular injection of contrast media, sorbitol and normal saline on the synovial membrane. MATERIALS AND METHODS Sixty three rabbits (126 knees) were used in this study. We injected the knees with amidotrizoate, ioxaglate, iopamidol, iotrol and diluted gadolinium-DTPA (2 mmol/l). Normal saline and sorbitol 27.25% were used for comparison. A histological and histochemical examination of the knees was carried out 1, 2, 10, 20, 30, 40 and 60 days after the injection. RESULTS On histological examination, the knees injected with normal saline, ioxaglate and gadolinium-DTPA had a normal appearance. Intra-articular injection of amidotrizoate, iopamidol, iotrol and sorbitol caused early, mild and transient histological changes of the synovium (synovial hyperplasia, infiltration by leucocytes). Furthermore, the knees injected with amidotrizoate presented with late, extensive histological changes (severe synovial hyperplasia, moderate vascular dilatation, severe infiltration by leukocytes). CONCLUSION The results suggest that the chemical structure and not the osmolality of the contrast media is the main cause for the histological changes of the synovium.
Collapse
|
23
|
Papacharalampous N, Primetis E, Beck A, Mundinger A, Vlahos L. Diagnostische Wertigkeit von MRT bei Schultergelenkerkrankungen. Klinische und operative Korrelation. ROFO-FORTSCHR RONTG 2005. [DOI: 10.1055/s-2005-867750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
24
|
Papacharalampous N, Patsouris E, Primetis E, Beck A, Mundinger A, Korkolopoulou P, Vlahos L. Experimentelle Untersuchungen zur Verträglichkeit von Kontrastmitteln bei der Arthrographie. ROFO-FORTSCHR RONTG 2005. [DOI: 10.1055/s-2005-867797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
25
|
Chatziioannou A, Mourikis D, Kalaboukas K, Ladopoulos C, Magoufis G, Primetis E, Katsenis K, Vlahos L. Endovascular Treatment of Renal Arteriovenous Malformations. Urol Int 2005; 74:89-91. [PMID: 15711117 DOI: 10.1159/000082716] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2003] [Accepted: 06/27/2003] [Indexed: 11/19/2022]
Abstract
We report a case of renal arteriovenous malformation treated with superselective endovascular embolization using a light mixture of n-butyl-2-cyanoacrylate and Lipiodol. Diagnostic imaging modalities and treatment methods are discussed. In conclusion, successful superselective embolization should be the standard of care.
Collapse
Affiliation(s)
- A Chatziioannou
- Department of Radiology, University of Athens, Areteion Hospital, Athens, Greece.
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Chatziioannou A, Brountzos E, Primetis E, Malagari K, Sofocleous C, Mourikis D, Kelekis D. Effects of Superselective Embolization for Renal Vascular Injuries on Renal Parenchyma and Function. Eur J Vasc Endovasc Surg 2004; 28:201-6. [PMID: 15234702 DOI: 10.1016/j.ejvs.2004.05.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2004] [Indexed: 11/24/2022]
Abstract
AIM Our objective was to evaluate the outcome of superselective embolization used for treatment of renal vascular injuries on renal parenchyma and renal function. MATERIALS AND METHODS Between January 1999 and December 2001, 6 consecutive patients (five males, one female, mean age 45 years) underwent embolization to treat bleeding from renal vascular injuries, resulting from iatrogenic interventions (4) and blunt abdominal trauma (2). Five patients had increased serum creatinine. Angiography depicted a pseudoaneurysm (PA) in three, PA with arteriovenous fistula (AVF) in one, and active extravasation in two patients. Superselective catheterization was achieved using a 5-F catheter in three, and coaxial microcatheter in the remaining three cases. All lesions were successfully embolized with 0.035" or 0.018" coils. RESULTS Bleeding was ceased in all patients and did not recur. Mean post-embolization parenchymal ischemic area was 11.7% (range: 0-30%). Imaging follow-up (mean: 12 months, range: 5-23) showed that mean parenchymal infarcted area was 6% (range: 0-15%). Serum creatinine level was normal in all patients one week after the procedure and at the latest follow-up. CONCLUSION Superselective embolization resulted in permanent cessation of bleeding. Serious parenchymal infarction was prevented and serum creatinine level returned to the pre-bleeding values. Embolization should be considered as the treatment of choice in this patient population.
Collapse
Affiliation(s)
- A Chatziioannou
- First Department of Radiology, Medical School, Areteion Hospital, Athens University, Athens, Greece
| | | | | | | | | | | | | |
Collapse
|