Effect of Locoregional Treatments in Hepatocellular Carcinoma: What Are the Pathologic/Radiologic Milan Criteria?

OBJECTIVES

Milan criteria is the most commonly used criteria for patients with hepatocellular carcinoma awaiting liver transplant. The effects of locoregional therapy on downstaging or bridging before liver transplant on survival remain controversial. Considering that the tumor size may change with locoregional therapy and formalin fixation after explantation, we aimed to evaluate the effects of locoregional therapy on radiological and pathological Milan criteria and survival.

MATERIALS AND METHODS

Demographic data, etiology, preoperative alpha-fetoprotein value, Child-Pugh and Model for End-Stage Liver Disease-Na scores, status of being inside or outside of radiological Milan criteria, status of being inside or outside of Milan criteria in explant (pathological Milan criteria), and the locoregional therapy types and combinations were evaluated for their effects on inclusion in Milan criteria and survival.

RESULTS

During the study period, 396 patients underwent liver transplant at our center, with 97 because of cirrhosis and hepatocellular carcinoma. When we viewed patients according to preoperative radiologic evaluations, 67.9% were within Milan criteria and 32.1% were outside. When we viewed according to explant (pathological) evaluations, 80.7% of patients were within Milan criteria. Among 97 patients, 71 (73.2%) had locoregional therapy (22 [30.9%] for downstaging, 49 [69.0%] for bridging to transplant), and 12 patients (12.3%) were within Milan criteria on explant examination while outside of Milan criteria before LT. One-year, 3-year, and 5-year survival rates were 80.7%, 76.1%, and 71.6%, respectively.

CONCLUSIONS

As a result of radiological evaluations, in patients who were outside of Milan criteria and underwent locoregional therapy, explant pathology within Milan criteria had a positive effect on survival; however, after locoregional therapy, there was no significant effect on survival in patients who were still outside of Milan criteria.

Internal versus external biliary drainage in malignant biliary obstructions: is there a difference in the rate of infection?

BACKGROUND

Percutaneous biliary drainage is a frequently used method to provide biliary decompression in patients with biliary obstruction.

PURPOSE

To investigate the between drainage type and infection risk in patients treated with internal-external and external biliary drainage catheterization for malignant biliary obstruction.

MATERIAL AND METHODS

A total of 410 patients with malignant biliary obstruction who underwent internal-external or external biliary drainage catheterization between January 2012 and October 2016 were retrospectively evaluated. We investigated the correlation between percutaneous biliary drainage technique and infection frequency by evaluating patients with clinical findings, bile and blood cultures, complete blood counts, and blood biochemistry.

RESULTS

There was no statistically significant difference between the selected patient groups (internal-external or external biliary drainage catheter placed) in terms of age, sex, primary diagnosis, receiving chemotherapy, catheter sizes, and outpatient-patient status. After catheterization, catheter-related infection was observed in 49 of 216 (22.7%) patients with internal-external and 18 of 127 (14.2%) patients with external biliary drainage catheters, according to the defined criteria. There was no difference in infection rate after the biliary drainage in the two groups (P > 0.05). There was also no difference concerning frequently proliferating microorganisms in bile cultures.

CONCLUSION

Internal-external biliary drainage catheter placement does not bring an additional infection risk for uninfected cholestatic patients whose obstruction could be passed easily in the initial drainage.

Comparison of severity and complication rates of acute cholecystitis during pandemic and pre-pandemic periods?

Background

Cancellations of surgeries for elective cases and late admissions of symptomatic cases during the pandemic period might have increased the number of cases of acute cholecystitis and its complications.

Purpose

To compare the severity of acute cholecystitis and complication rates during the pandemic and pre-pandemic periods.

Material and Methods

We evaluated the computed tomography (CT) findings observed for the diagnosis of complications for both acute simple and acute complicated cholecystitis during both the pandemic and pre-pandemic periods. Patients admitted to the hospital between March 2020 and December 2020 made up the study group and the corresponding appropriate patients from one year earlier were studied as the control group. In addition to the CT findings, clinical and laboratory findings, co-morbidities such as diabetes, as well as the admission time to hospital from the onset of the initial symptoms to hospital admission were also evaluated.

Results

A total of 88 patients were evaluated (54 in the study group, 34 in the control group; mean age = 64.3 ± 16.3 years). The male-to-female ratio was 51/37. The number of patients diagnosed with complicated cholecystitis were significantly higher in the study group ( P = 0.03). Murphy finding and diabetes status were similar between the two groups ( P = 0.086 and P = 0.308, respectively). Admission time to the hospital was significantly different for study and control groups in simple cholecystitis patients ( P = 0.045); with no significant difference in cases of complicated cholecystitis ( P = 0.499).

Conclusion

Our study reveals the course of acute cholecystitis during the pandemic period was much more serious with higher complications.

Arterial transit artifacts observed on arterial spin labeling perfusion imaging of carotid artery stenosis patients: What are counterparts on symptomatology, dynamic susceptibility contrast perfusion, and digital subtraction angiography?

PURPOSE

To investigate possible relationships between the presence and location of arterial transit artifacts (ATA) and clinical symptoms, digital subtraction angiography (DSA), and dynamic susceptibility contrast (DSC) perfusion imaging abnormalities in patients with carotid artery stenosis (CAS).

METHODS

Forty-seven patients who underwent arterial spin labeling (ASL) and DSC perfusion imaging in the same period diagnosed with > 50% unilateral internal carotid artery (ICA) stenosis by DSA performed 24 h after perfusion imaging were included. The presence of ATA, localization and hypoperfusion were evaluated using ASL interpretation. Maps derived from DSC perfusion, symptomatology, stenosis rates, and collateralization findings observed in DSA were investigated. Probable relationships were evaluated.

RESULTS

ATA on ASL were detected in 68.1% (32/47); 40.6% (13/32) of ATAs were observed in the distal middle cerebral artery (MCA) trace, 50% (16/32) in the intracranial ICA and MCA traces, and 9.4% (3/32) in the intracranial ICA trace. When classifications based on the ATA presence and localization was made, qualitative and quantitative CBF, MTT, and TTP abnormalities, symptomatology, stenosis rates, and collateralization findings significantly differed between groups (p < 0.05).

CONCLUSION

The presence and localization of ATA in patients with CAS may provide essential insights into cerebral hemodynamics and the CAS severity. ATAs observed only in the distal MCA trace may represent early-stage perfusion abnormalities and a moderate level of stenosis. ATA in the ICA trace may related to a more advanced level of perfusion abnormalities, critical stenosis rates, symptom or collateralization presence.

The association between the CT severity index and the pulmonary artery area in COVID-19 pneumonia

BACKGROUND

The pulmonary artery area (PAA) is a valuable non-invasive method for the diagnosis of pulmonary hypertension.

PURPOSE

To compare the change in PAA in patients with COVID-19 with the computed tomography (CT) severity index using follow-up imaging.

MATERIAL AND METHODS

A total of 81 patients who were followed up and underwent CT assessment more than once at our hospital's pandemic department were evaluated retrospectively. Patients with progression were separated into three groups: progression ranging from mild-to-mild infiltration (Group A, CT severity index of 0-2); progression from mild to severe infiltration (Group B, CT severity index of 0-2 to 3-5); and progression from severe-to-severe infiltration (Group C, CT severity index of 3-5). The PAAs were calculated separately.

RESULTS

The mean age was 56 ± 12 years. In terms of those patients showing progression in the CT images, the number of patients in Groups A, B, and C was 29, 40, and 12 in the right lung; 32, 45, and 4 in the left lung; 23, 45, and 13 on both lungs, respectively. There was no significant difference between the main, right, and left PAAs in Group A (P > 0.05). In Group B, there were significant increases in the areas of the main, right, and left PAAs (P < 0.05). There were also significant increases in the areas of the right and main pulmonary arteries in Group C (P < 0.05).

CONCLUSION

PAAs increase as disease involvement advances in cases with COVID-19 pneumonia, which is thought to be correlated with progression.

An assessment of SLAP type 5 lesions using proton density oblique sagittal imaging in magnetic resonance arthrography

BACKGROUND

Bankart lesions accompany superior labrum anteroposterior (SLAP) lesions; these are called SLAP type 5.

PURPOSE

To compare SLAP type 5 lesions using routine magnetic resonance arthrography (MRA) and thin-slice oblique sagittal proton density (PDW) sequences and correlation operation results.

MATERIAL AND METHODS

In total, 181 patients were admitted with shoulder instability. The study was completed with 44 patients. The presence or absence of isolated Bankart and SLAP type 5 lesions in routine MRA and PDW oblique sagittal images were evaluated separately. Absence of rupture scored 0 points, suspected ruptures scored 1 point, and apparent ruptures scored 2 points. The two scores were compared with the shoulder arthroscopy findings.

RESULTS

According to the findings in the shoulder arthroscopy, 40 patients had Bankart lesions and 17 patients had accompanying SLAP type 5 lesions. To detect a Bankart lesion, there was no significant difference between routine MRA sequences and PDW oblique sagittal images (P = 0.061). Routine MRA sensitivity was 95%, specificity 25%, positive predictive value (PPV) 92%, negative predictive value (NPV) 33%, while for PDW oblique sagittal images, sensitivity was 75%, specificity 100%, PPV 100%, and NPV 28.5%. In 8/17 type 5 SLAP lesions, routine MRA detected sensitivity 47%, specificity 92.6%, PPV 80%, and NPV 73.5%; in 14/17 SLAP type 5 lesions, PDW oblique sagittal images detected sensitivity 82%, specificity 100%, PPV 100%, and NPV 90% (P = 0.015).

CONCLUSION

The PDW oblique sagittal images may play a significant role in assessing the anterior and superior extent of the tears.

Diagnostic utility of superb microvascular imaging in depiction of corkscrew collaterals in Buerger's disease

PURPOSE

To evaluate the corkscrew collaterals in Buerger's disease by superb microvascular imaging (SMI) and power Doppler ultrasonography (PDU).

METHODS

We evaluated with SMI and PDU 14 patients with Buerger's disease in whom corkscrew collaterals had been identified on digital subtraction angiography (DSA). Corkscrew collaterals were classified on DSA and PDU based on their size and morphology.

RESULTS

A total of 17 vascular regions of collateral vessel formation were assessed. Based on DSA classification, there were three cases of type I collaterals (arterial diameter of >2 mm with large helical pattern), seven cases of type III collaterals (arterial diameter of 1-1.5 mm with small helical pattern), and seven cases of type IV collaterals (arterial diameter of <1 mm with tiny helical pattern). On PDU, all type I collaterals on DSA appeared as "large snake" images, all type III collaterals on DSA appeared as "small snake" images, and all type IV collaterals on DSA appeared as dots. SMI imaging, both in color and monochrome mode, provided superior demonstration of the continuity of the vessel of large or small "snake" images. In cases appearing as dot pattern on PDU, color SMI was able to show continuity of the flow signal as a helical pattern.

DISCUSSION

SMI is a promising new Doppler imaging technique that is superior to conventional power Doppler imaging in depiction and identification of corkscrew collaterals in Buerger's disease.

Direct aspiration thrombectomy experience with the SOFIA 6F catheter in acute ischemic stroke

INTRODUCTION

As the SOFIA (Soft torqueable catheter Optimized For Intracranial Access) 6F catheter has a large luminal diameter, it can be used as an aspiration catheter. Furthermore, it may function as an intermediate catheter when a stent retriever is required.

PURPOSE

We aimed to evaluate the usefulness of the SOFIA 6F catheter in mechanical thrombectomy with the direct aspiration first pass technique.

METHOD

Patients who had undergone mechanical thrombectomy (September 2017-January 2019) using the SOFIA 6F catheter in two centers were retrospectively analyzed. We used the thrombolysis in cerebral infarction (TICI) scale to evaluate the success of recanalization. National Institutes of Health Stroke Scale scores on admission and discharge were used together with the modified Rankin Scale (mRS) scores at 90 days.

RESULTS

In 132 (89.1%) of the 148 cases, the thrombus was in the anterior system. The SOFIA 6F catheter reached the thrombus site in 130 (87.8%) cases. The rate of successful recanalization (TICI ≥ 2b) was 89.1%. The targeted clinical outcome (mRS score ≤ 2 at 90th days) was achieved in 49.3% of cases. Symptomatic intracranial hemorrhage occurred in 5.4%. The rate of emboli to new vascular territories was 5.4%. Mortality was 14.1%.

CONCLUSION

In the majority of our cases, the SOFIA 6F catheter provided effective and rapid recanalization with aspiration thrombectomy.

Endovascular Treatment in Traumatic and Spontaneous Carotid Cavernous Fistulas: with Different Embolization Agents and via Various Vascular Routes

PURPOSE

We evaluated carotid cavernous fistula (CCF) cases which were treated with various vascular routes and different embolization agents. Our aim was to present endovascular treatment procedures, clinical and radiological findings, and to discuss the safety and clinical efficacy of the treatment.

MATERIALS AND METHODS

The demographic information, presenting symptoms and clinical findings of 25 CCF cases in 23 patients treated with endovascular route were reviewed. The type of fistula, the feeding arteries, the draining veins, and the details of the treatment were documented on the basis of digital subtraction angiography (DSA) images. The efficacy of the treatment was evaluated according to current and follow-up DSA findings with clinical symptoms.

RESULTS

All of which 25 CCF were closed to the fullest extent, one of them closed spontaneously, 20 were closed in one session and 4 in two sessions (100%). 18 of the cases (75%; 18/24) were treated with a venous approach, 5 cases (21%; 5/24) with an arterial approach, and 1 case (4%; 1/24) with a combined arterial-venous approach. Coils were used in 18 cases (75%; 18/24), a covered stent was used in 1 case (4%; 1/24), a detachable balloon was used in 1 case (4%; 1/24), n-Butyl Cyanoacrylate was used in 1 case (4%; 1/24), and combined (2 stent-coil, 1 coil-ethylene vinyl alcohol copolymer) embolization agents were used.

CONCLUSION

The endovascular treatment of CCF has high success and low complication rates. The significant point of the treatment is achieving complete fistula obliteration in the least possible number of sessions with appropriate embolization agents.

The effect of gigantomasty on vertebral degeneration: A computed tomography study

The main reason for waist and back pain in patients with gigantomasty is increased thoracic kyphosis and lumber lordosis. These symptoms and abnormal spinal angulations regress after reduction mammoplasty operations. However, the effect of chronic mechanical stress caused by gigantomasty on the spinal degenerative process is not clear yet. In this study with computed tomography it is shown that degenerative spondylosis is more widespread and severe in patients with large breasts.

Percutaneous Coil Embolization for the Treatment of a Giant Brachial Artery Pseudoaneurym in a Child

Brachial artery pseudoaneurysm is a rare phenomenon. When a diagnosis of brachial artery pseudoaneurysm is established, early and appropriate treatment should be performed as soon as possible to prevent possible complications, such as hemorrhage, rupture, and upper limb and finger losses. Open surgical repair is usually the cornerstone of treatment; however, we here report a case of giant brachial pseudoaneurysm in a 2-year-old girl, which was successfully treated with percutaneous coil embolization.

Spontaneous occlusion of cerebral arteriovenous malformation following partial embolization with Onyx

Management options for brain arteriovenous malformations (AVMs) are surgery, radiosurgery, and endovascular embolization. The aim of partial embolization in endovascular treatment is to make total resection possible. However, increased risk of bleeding in partial embolization creates some controversies about treatment options. Spontaneous total occlusion of cerebral AVMs following partial obliteration with embolization agents is a rarely seen condition. We present a case with an AVM vanishing from right posterior cerebral artery which spontaneously occluded following partial embolization with Onyx liquid agent.

Retrievable Stent-Assisted Coiling Technique Using a Solitaire Stent: Treatment of Pancreaticoduodenal Artery Aneurysm Associated With Celiac Artery Occlusion

True aneurysm of pancreaticoduodenal arcade (PDA) is usually accompanied by stenosis or occlusion of celiac trunk (CeT). The up-to-date and first choice treatment modality of PDA aneurysm is the endovascular approach in nearly all cases except few selected ones necessitating surgery. The main approach in endovascular treatment is embolization of the aneurysm by preserving the parent artery. A case with concomitant CeT occlusion and PDA aneurysm was treated with coil embolization by preserving inferior pancreaticoduodenal artery with retrievable Solitaire(®) stent. In our knowledge, this is the first case with PDA aneurysm treated with this technique.

Dissection of a non-bifurcating cervical carotid artery

A non-bifurcating cervical carotid artery is a rare anomaly in the population. Radiologic diagnosis of pathologies seen together with this anomaly can be challenging. Despite not being diagnostic all the time, digital subtraction angiography is accepted as the gold standard method for the diagnosis of dissection. We present a case of a non-bifurcating cervical carotid artery and concomitant dissection, which presented to the hospital with trauma and ischemic findings.

The Effect of Stent Cell Geometry on Carotid Stenting Outcomes

PURPOSE

The aim of this study was to investigate the effect of stent cell geometry on midterm results of carotid artery stenting (CAS).

MATERIALS AND METHOD

One hundred fifty-five patients underwent CAS between February 2010 and December 2012. Ninety-one open- and 84 closed-cell stents were used in this non-randomized, retrospective study. Periprocedural complications were defined as the ones happened during the procedure or within 30 days afterwards. Starting from the 6th month after the procedure, in-stent restenosis was detected with multidetector computed tomography angiography and classified into four groups from focal restenosis to occlusion.

RESULTS

Eleven complications were encountered in the periprocedural period (four on the open- and seven on the closed-cell group). Total complication rate was 6.3% (11/175). No significant difference was detected in terms of periprocedural complications between two groups (p = 0.643). There was statistically significant difference between stent design groups in regard to radiological findings (p = 0.002). Sixteen of open-cell stents and three of closed-cell stents had focal restenosis. One closed-cell stent had diffuse proliferative restenosis and one open-cell stent had total occlusion.

CONCLUSION

In-stent restenosis was more common in open-cell stent group, which have larger free cell area than closed-cell stents. Although our radiologic findings promote us to use closed-cell design if 'possible', no difference was detected in terms of clinical outcomes.

Modified Y-configured stents with the waffle-cone technique by use of Solitaire® stent for patients with wide-necked bifurcation aneurysms

Endovascular treatment of wide-necked bifurcation aneurysms can be challenging, despite improvements in endovascular techniques. Y stent-assisted coiling is one such technique, but this may not be technically feasible, especially in cases of acute angulation between the proximal and distal parent arteries, and may require use of "modified Y-configured stents with the waffle-cone technique". We report three cases of wide-necked bifurcation aneurysms that were successfully treated by use of the Solitaire® stent.

Rare use of twin Solitaire® stents in the double waffle-cone technique for endovascular treatment of a wide-necked bifurcation aneurysm

Endovascular treatment of wide-necked bifurcation aneurysms may be challenging. The waffle-cone technique can be used in these aneurysms in case of acute angulation between parent artery and distal artery of the aneurysm. Solitaire® stent (Ev3, Irvine, CA, USA) has the significant advantage of mitigating the potential complication risks. This study reports the second case in the literature in which endovascular treatment of a wide-necked bifurcation aneurysm with the double waffle-cone technique by using twin Solitaire® stents proved to be successful.

Contribution of thin-slice (1 mm) axial proton density MR images for identification and classification of meniscal tears: correlative study with arthroscopy

OBJECTIVE

To evaluate the diagnostic efficacy of thin-slice (1 mm) axial proton density-weighted (PDW) MRI of the knee for meniscal tear detection and classification.

METHODS

We prospectively assessed pre-operative MR images of 58 patients (41 males, 17 females; age range 18-62 years) with arthroscopically confirmed meniscal tear. First, we evaluated the performance of the sagittal and thin-slice axial MR images for the diagnosis of meniscal tears. Second, we compared the correlation of tear types presumed from sagittal and axial MRI with arthroscopy and tear classification from axial MRI. Tears were classified on the sagittal plane and the axial plane separately. The diagnostic performance and tear classification were compared statistically with arthroscopy results, which is accepted as the standard of reference.

RESULTS

8 of 58 patients were removed from the study group because they had complex or degenerative tears. A total of 62 tears were detected with arthroscopy in 50 patients. On the sagittal images, sensitivity and specificity values were 90.62% and 70.37%, respectively, for medial meniscus tears and 72.73% and 77.14%, respectively, for lateral meniscus tears. The corresponding values for axial images were 97.30% and 84.00%, respectively, for medial meniscus tears and 95.65% and 80.50%, respectively, for lateral meniscus tears. There was no significant difference in tear classification between the arthroscopy results and the thin-slice axial PDW MRI results (p>0.05).

CONCLUSION

thin-slice axial PDW MRI increases the sensitivity and specificity of meniscal tear detection and especially classification, which is important for surgical procedure decisions.