Abstract: Bleeding from mesenteric varices associated with portal hypertension is occasionally life-threatening. A 53-year-old man who had undergone esophageal transection for esophageal varices and balloon-occluded retrograde transvenous obliteration for gastric varices presented with melena due to ruptured mesenteric varices. He was treated by injecting N-butyl-2-cyanoacrylate via an abdominal wall vein to obtain retrograde transvenous obliteration.
AIM: To compare the liver transplantation-free (LTF) survival rates between patients who underwent transjugular intrahepatic portosystemic shunts (TIPS) and those who underwent paracentesis by an updated meta-analysis that pools the effects of both number of deaths and time to death.
Hepatocellular carcinoma (HCC) is the fifth most common tumor worldwide. Multiple treatment options are available for HCC including curative resection, liver transplantation, radiofrequency ablation, trans-arterial chemoembolization, radioembolization and systemic targeted agent like sorafenib. The treatment of HCC depends on the tumor stage, patient performance status and liver function reserve and requires a multidisciplinary approach. In the past few years with significant advances in surgical treatments and locoregional therapies, the short-term survival of HCC has improved but the recurrent disease remains a big problem. The pathogenesis of HCC is a multistep and complex process, wherein angiogenesis plays an important role. For patients with advanced disease, sorafenib is the only approved therapy, but novel systemic molecular targeted agents and their combinations are emerging. This article provides an overview of treatment of early and advanced stage HCC based on our extensive review of relevant literature.
Radiofrequency ablation (RFA) is commonly applied for the treatment of hepatocellular carcinoma (HCC) because of the facile procedure, and the safety and effectiveness for the treatment of this type of tumor. On the other hand, it is believed that HCC cells should spread predominantly through the blood flow of the portal vein, which could lead to the formation of intrahepatic micrometastases. Therefore, monitoring tumor response after the treatment is quite important and accurate assessment of treatment response is critical to obtain the most favorable outcome after the RFA. Indeed, several reports suggested that even small HCCs of ≤ 3 cm in diameter might carry intrahepatic micrometastases and/or microvascular invasion. From this point of view, for preventing local recurrences, RFA should be performed ablating a main tumor as well as its surrounding non-tumorous liver tissue where micrometastases and microvascular invasion might exist. Recent advancement of imaging modalities such as contrast-enhanced ultrasonic, computed tomography, and magnetic resonance imaging are playing an important role on assessing the therapeutic effects of RFA. The local recurrence rate tends to be low in HCC patients who were proven to have adequate ablation margin after RFA; namely, not only disappearance of vascular enhancement of main tumor, but also an adequate ablation margin. Therefore, contrast enhancement gives important findings for the diagnosis of recurrent HCCs on each imaging. However, hyperemia of non-tumorous liver surrounding the ablated lesion, which could be attributed to an inflammation after RFA, may well obscure the findings of local recurrence of HCCs after RFA. Therefore, we need to carefully address to these imaging findings given the fact that diagnostic difficulties of local recurrence of HCC. Here, we give an overview of the current status of the imaging assessment of HCC response to RFA.
Barrett’s oesophagus (BO) is a usually indolent condition that occasionally requires endoscopic therapy. Radiofrequency ablation (RFA) is an effective endoscopic treatment for high grade dysplasia (HGD) and intramucosal cancer in BO. It has a good efficacy, durability and safety profile although complications can occur. Here we describe a case of RFA in a patient with high grade dysplasia. Although the response to treatment was initially very good with the development of neosquamous epithelium, the patient very rapidly developed a squamous cell cancer of the oesophagus confirmed on radiology, histology and immunohistochemistry. Sanger sequencing confirmed that the original HGD and the squamous cell cancer (SCC) were derived from separate clonal origins. The report highlights the fact that SCC of the oesophagus has been noted after endoscopic ablation for BO previously and suggest that ablation of BO may encourage the clonal expansion of cells carrying carcinogenic mutations once a dominant clonal population has been eradicated.
Transarterial chemoembolization (TACE) is the first line treatment for patients with intermediate stage hepatocellular carcinoma but is also increasingly being used for patients on the transplant waiting list to prevent further tumor growth. Despite its widespread use, TACE remains an unstandardized procedure, with variation in type and size of embolizing particles, type and dose of chemotherapy and interval between therapies. Existing evidence from randomized controlled trials suggest that bland transarterial embolization (TAE) has the same efficacy with TACE. In the current article, we review the use of TACE and TAE for hepatocellular carcinoma and we focus on the evidence for their use.
Rectal cancer is a common cancer and a major cause of mortality in Western countries. Accurate staging is essential for determining the optimal treatment strategies and planning appropriate surgical procedures to control rectal cancer. Endorectal ultrasonography (EUS) is suitable for assessing the extent of tumor invasion, particularly in early-stage or superficial rectal cancer cases. In advanced cases with distant metastases, computed tomography (CT) is the primary approach used to evaluate the disease. Magnetic resonance imaging (MRI) is often used to assess preoperative staging and the circumferential resection margin involvement, which assists in evaluating a patient’s risk of recurrence and their optimal therapeutic strategy. Positron emission tomography (PET)-CT may be useful in detecting occult synchronous tumors or metastases at the time of initial presentation. Restaging after neoadjuvant chemoradiotherapy (CRT) remains a challenge with all modalities because it is difficult to reliably differentiate between the tumor mass and other radiation-induced changes in the images. EUS does not appear to have a useful role in post-therapeutic response assessments. Although CT is most commonly used to evaluate treatment responses, its utility for identifying and following-up metastatic lesions is limited. Preoperative high-resolution MRI in combination with diffusion-weighted imaging, and/or PET-CT could provide valuable prognostic information for rectal cancer patients with locally advanced disease receiving preoperative CRT. Based on these results, we conclude that a combination of multimodal imaging methods should be used to precisely assess the restaging of rectal cancer following CRT.
Radiofrequency ablation (RFA) has become an important option in the therapy of primary and secondary hepatic tumors. Surgical resection is still the best treatment option, but only a few of these patients are candidates for surgery: multilobar disease, insufficient liver reserve that will lead to liver failure after resection, extra-hepatic disease, proximity to major bile ducts and vessels, and co-morbidities. RFA has a low mortality and morbidity rate and is considered to be safe. Thus, complications occur and vary widely in the literature. Complications are caused by thermal damage, direct needle injury, infection and the patient’s co-morbidities. Tumor type, type of approach, number of lesions, tumor localization, underlying hepatic disease, the physician’s experience, associated hepatic resection and lesion size have been described as factors significantly associated with complications. The physician in charge should promptly recognize high-risk patients more susceptible to complications, perform a close post procedure follow-up and manage them early and adequately if they occur. We aim to describe complications from RFA of hepatic tumors and their risk factors, as well as a few techniques to avoid them. This way, others can decrease their morbidity rates with better outcomes.
Peripheral arterial disease (PAD) affects approximately 8 million patients in the United States, with prevalence projected to increase as the population ages (1). Evaluation of the entire peripheral arterial tree is essential for revascularization planning, with gadolinium-enhanced magnetic resonance (MR) angiography or computed tomographic (CT) angiography as widely used noninvasive tests (2–5). CT angiography provides rapid, high-spatial-resolution assessment, attractive where MR imaging is contraindicated by claustrophobia or implants (6). However, CT becomes less reliable where heavy arterial calcification is present (7) and places patients with renal impairment at risk for contrast material–induced nephrotoxicity (8), with renal impairment common in PAD (9). Contrast material–enhanced MR angiography is of concern in severe renal insufficiency, because of the risk of nephrogenic systemic fibrosis (10,11). A relatively rapid, reliable MR angiographic technique independent of gadolinium-based contrast material is desirable.
The nephrotoxic potential of iodinated contrast media is widely accepted in the medical literature (1–5). Such injury, termed contrast material–induced nephropathy (CIN), is typically defined as an absolute or percentage increase in serum creatinine (SCr) level over baseline. Recently, however, the causal link between intravenous iodinated contrast material and nephrotoxicity has come under scrutiny based on several observations (6,7). First, the presumed nephrotoxicity of intravenous contrast material has been largely extrapolated from more invasive angiocardiographic studies of intraarterial contrast material administration (6). Second, because these intraarterial studies inherently lack control groups where contrast material was not administered, they cannot extricate the true incidence of CIN from iatrogenic and physiologic confounders that also elevate SCr (8,9). Third, only a small fraction of CIN studies were directly focused on intravenous contrast material use, and of those, only 13 included control groups where contrast material was not administered (10–22). Collectively, these 13 controlled studies paradoxically demonstrated that acute kidney injury (AKI) is as common if not more common in patients not exposed to contrast material compared with contrast material–exposed patients (23).
More than 30 million iodinated contrast material–enhanced computed tomographic (CT) scans are obtained annually in the United States, making iodinated contrast medium one of the most prescribed agents in current medical practice (1). In these CT scans, intravenous (IV) iodinated contrast material is used to enhance tissue conspicuity and thus improve the diagnostic accuracy of the examinations. This benefit notwithstanding, administration of IV iodinated contrast medium has been causally associated with the development of acute kidney injury (AKI), known as contrast medium–induced nephropathy (CIN), particularly among individuals with preexisting renal dysfunction (2–7). In an effort to reduce the incidence of CIN, the American College of Radiology, the Canadian Association of Radiologists, and the European Society of Urogenital Radiology have all published guidelines for IV contrast medium administration on the basis of prescanning serum creatinine (SCr) values (8–10). This practice frequently results in withholding contrast medium in at-risk individuals, often at the expense of diagnostic accuracy.
The detection of renal cell carcinoma (RCC) has been increasing because of widespread use of cross-sectional imaging performed for other indications (1,2). Traditionally, radical nephrectomy has been regarded as the criterion standard for the treatment of RCC (3). Recently, nephron-sparing techniques, such as partial nephrectomy or local ablation therapy, have been increasingly performed for the treatment of small RCC in an attempt to preserve renal function and decrease mortality (4,5).
Fine-needle aspiration biopsy (FNAB) is known as the most accurate and cost-effective method for evaluating thyroid nodules (1). When a nodule is diagnosed as benign at FNAB, further immediate diagnostic examinations or treatments are not routinely needed (2). However, the general recommendation is that all benign thyroid nodules should be followed with serial ultrasonographic (US) examinations 6–18 months after initial FNAB (2) because of intercenter variability in the performance of diagnosis at FNAB and a false-negative rate of 5%–10% (2–6). Although nodule growth is not itself pathognomonic for malignancy, if there is evidence of nodule growth at a follow-up US examination, repeat FNAB is recommended (2,7).
The first studies on renal denervation (RDN) suggest that this treatment is feasible, effective, and safe in the short term. Presently available data are promising, but important uncertainties exist; therefore, SYMPATHY has been initiated. SYMPATHY is a multicenter, randomized, controlled trial in patients randomized to RDN in addition to usual care (intervention group) or to continued usual care (control group). Randomization will take place in a ratio of 2 to 1. At least 300 participants will be included to answer the primary objective. Sample size may be extended to a maximum of 570 to address key secondary objectives. The primary objective is to assess whether RDN added to usual care compared with usual care alone reduces blood pressure (BP) (ambulatory daytime systolic BP) in subjects with an average daytime systolic BP ≥135, despite use of ≥3 BP-lowering agents, 6 months after RDN. Key secondary objectives are evaluated at 6 months and at regular intervals during continued follow-up and include the effect of RDN on the use of BP-lowering agents, in different subgroups (across strata of estimated glomerular filtration rate and of baseline BP), on office BP, quality of life, and cost-effectiveness.
Purpose: To describe the experience and results from the roll-in phase of the Cardiovascular Outcomes with Renal Atherosclerotic Lesions (CORAL) study.
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