Most patients with pancreatic cancer develop malignant biliary obstruction. Treatment of obstruction is generally indicated to relieve symptoms and improve morbidity and mortality. First-line therapy consists of endoscopic biliary stent placement. Recent data comparing plastic stents to self-expanding metallic stents (SEMS) has shown improved patency with SEMS. The decision of whether to treat obstruction and the means for doing so depends on the clinical scenario. For patients with resectable disease, preoperative biliary decompression is only indicated when surgery will be delayed or complications of jaundice exist. For patients with locally advanced disease, self-expanding metal stents are superior to plastic stents for long-term patency. For patients with advanced disease, the choice of metallic or plastic stent depends on life expectancy. When endoscopic stent placement fails, percutaneous or surgical treatments are appropriate. Endoscopic therapy or surgical approach can be used to treat concomitant duodenal and biliary obstruction.
AIM: To evaluate the feasibility of a second parallel transjugular intrahepatic portosystemic shunt (TIPS) to reduce portal venous pressure and control complications of portal hypertension.
AIM: To evaluate the usefulness of three-dimensional (3D) shear-wave elastography (SWE) in assessing the liver ablation volume after radiofrequency (RF) ablation.
AIM: To compare the efficacy of different chemotherapeutic agents during conventional transarterial chemoembolization (cTACE) in the treatment of unresectable hepatocellular carcinoma (HCC).
Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide and leading cause of death among patients with cirrhosis. Treatment guidelines are based according to the Barcelona Clinic Liver Cancer staging system. The choice among therapeutic options that include liver resection, liver transplantation, locoregional, and systemic treatments must be individualized for each patient. The aim of this paper is to review the outcomes that can be achieved in the treatment of HCC with the heterogeneous therapeutic options currently available in clinical practice.
Liver transplantations were performed on two patients with hepatic failure caused by liver cirrhosis. Hard obsolete thrombi and portal venous sclerosis were observed in the major portal veins of both patients. The arteria colica media of one recipient and the portal vein of the donor were anastomosed end-to-end. The hepatic artery of the first donor was anastomosed end-to end with the gastroduodenal artery of the first recipient; meanwhile, the portal vein of the second donor was simultaneously anastomosed end- to-end with the common hepatic artery of the second recipient. The blood flow of the portal vein, the perfusion of the donor liver and liver function were satisfactory after surgery. Portal vein arterialization might be an effective treatment for patients whose portal vein reconstruction was difficult.
Colorectal cancer (CRC) is the 3rd most common cancer in the United States with more than 10000 new cases diagnosed annually. Approximately 20% of patients with CRC will have distant metastasis at time of diagnosis, making them poor candidates for primary surgical resection. Similarly, 8%-25% of patients with CRC will present with bowel obstruction and will require palliative therapy. Emergent surgical decompression has a high mortality and morbidity, and often leads to a colostomy which impairs the patient’s quality of life. In the last decade, there has been an increasing use of colonic stents for palliative therapy to relieve malignant colonic obstruction. Colonic stents have been shown to be effective and safe to treat obstruction from CRC, and are now the therapy of choice in this scenario. In the setting of an acute bowel obstruction in patients with potentially resectable colon cancer, stents may be used to delay surgery and thus allow for decompression, adequate bowel preparation, and optimization of the patient’s condition for curative surgical intervention. An overall complication rate (major and minor) of up to 25% has been associated with the procedure. Long term failure of stents may result from stent migration and tumor ingrowth. In the majority of cases, repeat stenting or surgical intervention can successfully overcome these adverse effects.
Hepatocellular carcinoma (HCC) is the sixth most common cancer and third leading cause of cancer-related death in the world. The Barcelona clinic liver cancer classification is the current standard classification system for the clinical management of patients with HCC and suggests that patients with intermediate-stage HCC benefit from transcatheter arterial chemoembolization (TACE). Interventional treatments such as TACE, balloon-occluded TACE, drug-eluting bead embolization, radioembolization, and combined therapies including TACE and radiofrequency ablation, continue to evolve, resulting in improved patient prognosis. However, patients with advanced-stage HCC typically receive only chemotherapy with sorafenib, a multi-kinase inhibitor, or palliative and conservative therapy. Most patients receive palliative or conservative therapy only, and approximately 50% of patients with HCC are candidates for systemic therapy. However, these patients require therapy that is more effective than sorafenib or conservative treatment. Several researchers try to perform more effective therapies, such as combined therapies (TACE with radiotherapy and sorafenib with TACE), modified TACE for HCC with arterioportal or arteriohepatic vein shunts, TACE based on hepatic hemodynamics, and isolated hepatic perfusion. This review summarizes the published data and data on important ongoing studies concerning interventional treatments for unresectable HCC and discusses the technical improvements in these interventions, particularly for advanced-stage HCC.
AIM: To define the histopathological features predictive of post-transplant hepatocellular carcinoma (HCC) recurrence after transarterial chemoembolization, applicable for recipient risk stratification.
AIM: To evaluate the efficacy of stents in treating patients with anastomotic site obstructions due to cancer recurrence following colorectal surgery.
Cardiovascular diseases remain the leading cause of morbidity and mortality in the Western world and developing countries (1). Coronary artery disease (CAD) causes the majority of events resulting in cardiovascular mortality and morbidity, while carotid disease is a major contributor to the development of ischemic stroke (1). In clinical practice, early identification and characterization of unstable atherosclerotic lesions that might cause these complications remains challenging. Evidence is mounting that a substantial part of ruptured plaques resides in vessels with less than 60% stenosis (2–4). A priori detection of vulnerable plaques is therefore an increasing clinical need but requires new imaging techniques that provide information on plaque composition and biologic processes associated with plaque progression and destabilization. Imaging methods limited to the assessment of arterial luminal diameter are still considered the reference standard for the diagnosis of clinically significant CAD and carotid artery disease and guidance of treatment. Severe atherosclerotic vessel wall changes can be missed at x-ray angiography, as positive remodeling can occur without visually apparent luminal narrowing (5). Atherosclerotic plaques with positive remodeling were shown to be associated with a higher risk of rupture (6).
Axillary lymph node (LN) dissection (ALND) is associated with considerable morbidity that negatively affects patients’ quality of life and has no benefit in terms of the overall survival rate. Axillary nodal status remains a major prognostic factor and might influence treatment options (1–3). The current standard of care for staging the axilla is sentinel LN biopsy (SLNB), and typically, only patients with LNs positive for metastasis require further care, eliminating the need for routine ALND (2,4). Less aggressive axillary surgery is beneficial, resulting in reduced arm stiffness, pain, paraesthesia, and risk of lymphedema (5).
Rectal cancer is a major cause of mortality in the United States, and there were an estimated 40 290 new cases in 2012 (1,2). Treatment of patients with rectal cancer is based on individual risk factors for recurrence in each patient (3). Patients with a high risk for local recurrence are generally treated with long-term neoadjuvant chemotherapy and radiation therapy (hereafter, chemoradiotherapy) to downstage and increase the chance of a curative resection (3–5). Accurate restaging is increasingly important for patients with locally advanced rectal cancer undergoing neoadjuvant treatment, because identification of response has major implications for management (6).
This two-part review discusses the current state of the art for computed tomography (CT)- and magnetic resonance (MR) imaging–based diagnosis and staging of hepatocellular carcinoma (HCC). The first article reviewed basic background material including HCC epidemiology, key concepts in hepatocarcinogenesis, CT and MR imaging technique, and the CT and MR imaging appearance of cirrhotic nodules, low-grade dysplastic nodules, and high-grade dysplastic nodules. This second article builds on these concepts and reviews in detail the diagnosis and staging of HCC using CT and MR imaging. In the article, we focus on CT and MR imaging because these currently are the most important modalities for HCC diagnosis and staging. Other imaging methods have been advocated for these purposes, including contrast material–enhanced ultrasonography (1), CT hepatic angiography and CT arterial portography (2), MR imaging with Kupffer cell agents (3), and positron emission tomography (4), but these modalities are utilized mainly as supplementary tests for select indications, not performed in many parts of the world, and hence not discussed here. While the emphasis is on diagnosis and staging, this article also reviews emerging roles of CT and MR imaging for predicting HCC tumor grade and other important biologic properties.
Ultrasonography (US)-guided ethanol ablation (EA) is an effective treatment modality for patients with thyroid nodules. Although EA is less effective when used to treat predominantly cystic or solid thyroid nodules (1,2), it is useful in the treatment of cystic thyroid nodules where cystic portions are greater than 90% and affords volume reductions of 85%–98.5% (3–8).
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