A Review Of Mri Appearances Of Lipiodol In Conventional Tace (Ctace) Treated Hepatocellular Carcinomas.

Background: The global burden of patients affected by chronic liver disease (CLD) has shown a steady rise over the last few decades and is now considered the 11th most frequent cause of death globally. In addition, as the world population is facing increased obesity rates coupled with alcohol consumption, these rates are predicted to continue to rise. The Objective was to assess the appearance of Lipiodol retention upon different MRI sequences with a special focus on non-contrast sequences. Lipiodol Trans-arterial chemoembolization (TACE) has become the standard treatment for unresectable hepatocellular carcinoma (HCC) without vascular invasion. However, data regarding Lipiodol TACE imaging via MRI is limited and results are not familiar to radiologists for regular assessment of treatment response. Methods: After IRB and EC approval, we included all those patients who underwent TACE treatment with Lipiodol and chemotherapeutic agent; having both 4-6-week post-treatment CT and MRI imaging. This criterion was fulfilled by a total of 25 patients. Only lipiodol-containing areas within the lesion were noted for signal intensities on all MRI sequences and labelled as hyperintense, isointense, hypointense and mixed intensity. Data was entered and analyzed by SPSS v27. Frequencies and percentages were calculated for qualitative data. Results: The most sensitive sequence in detecting Lipiodol retention was Fat suppressed T1 imaging sequence, with low signal intensity seen on T1 weighted fat-suppressed sequences in up to 76% of lesions. While on non-fat suppressed T1 weighted images, 60% of Lipiodol retention areas appeared hyperintense. 52% of lesions showed a hypointense appearance on the T2 weighted sequence. A much more variable appearance was seen in Diffusion-weighted imaging sequences demanding cautious interpretation. MR patterns were clearer in patients having more than 50% lipiodol retention on CT and lesion size more than 2 cm. . Conclusion: While MRI is deemed as a reliable and most useful imaging modality for assessing HCC's following lipiodol TACE it requires cautious interpretation with knowledge of variable signal appearance seen on different imaging sequences.

Saving The Uterus; Our Experience In Uterine Artery Embolization For Acquired Uterine Vascular Abnormalities.

Background: Acquired uterine vascular abnormalities are a rare cause of potentially life threatening bleeding. These include uterine artery pseudoaneurysms (UAP)and acquired arteriovenous malformations. The objective of this study was to describe our experience with the diagnosis of acquired uterine vascular abnormalities and its treatment with uterine preservation. It was a retrospective cohort study. Methods: Eight patients were enrolled from the hospital database who presented to our Interventional Radiology department from April 2017 to March 2021 for uterine artery embolisation (UAE) with a history of iatrogenic/acquired uterine vascular abnormalities confirmed on imaging. These included two patients with uterine artery pseudoaneurysm (PA) concurrently with arteriovenous malformation (AVM), one with uterine artery PA and five having uterine AVMs. Embolisation agents used were histoacryl glue, lipiodol, PVA particles, and gelfoam slurry. Medical records, imaging studies, and telephonic contact with patients were assessed for patient presentation, intraprocedural details, and follow up to record treatment success. Statistical analysis was performed using descriptive statistics. Results: Bilateral UAE was performed in six patients, while two patients underwent unilateral UAE. Three of the patients presented with life-threatening bleeds requiring multiple transfusions. Clinical as well as angiographic success was achieved in all patients with immediate control of haemorrhage. No complications were observed during follow-up. Two of the patients were able to conceive normally within one year, though it resulted in a miscarriage. Conclusion: Acquired/iatrogenic uterine vascular abnormalities are a rare but important cause of life-threatening haemorrhage that can be expertly managed and successfully treated using UAE, which is rapid, safe, and minimally invasive, with the added advantage fertility preservation.

Living donor liver transplantation for advanced hepatocellular carcinoma including macrovascular invasion.

BACKGROUND: The indications for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) continue to evolve. The aim of this study was to report outcomes in patients who underwent living donor liver transplantation (LDLT) for HCC outside traditional criteria including macrovascular invasion (MVI). METHODS: We reviewed outcomes in patients who met the University of California San Francisco (UCSF) criteria (n = 159) and our center-specific criteria (UCSF+) (largest tumor diameter ≤ 10 cm, any tumor number, AFP ≤ 1000 ng/ml) (n = 58). We also assessed outcomes in patients with MVI (n = 27). RESULTS: The median follow was 28 (10.6-42.7) months. The 5 year overall survival and risk of recurrence (RR) in the UCSF and UCSF + group was 71% vs 69% (P = 0.7) and 13% vs 36% (P = 0.1) respectively. When patients with AFP > 600 ng/ml were excluded from the UCSF + group, RR was 27% (P = 0.3). Among patients with MVI who had downstaging (DS), 4/5(80%) in low-risk group (good response and AFP ≤ 100 ng/ml) and 2/10 (20%) in the high-risk group (poor response or AFP > 100 ng/ml) were alive at the last follow-up. When DS was not feasible, 3/3 (100%) in the low-risk group (AFP ≤ 100 ng/ml + Vp1-2 MVI) and 1/9 (9.1%) in the high-risk group (AFP > 100 or Vp3 MVI) were alive. The 5 year OS in the low-risk MVI group was 85% (P = 0.003). CONCLUSION: With inclusion of AFP, response to downstaging and degree of MVI, acceptable survival can be achieved with LDLT for HCC outside traditional criteria.

Risk Score Model for Liver Transplant Outcomes after Preoperative Locoregional Therapy for Hepatocellular Carcinoma.

PURPOSE: The role of preoperative locoregional therapy (LRT) for hepatocellular carcinoma (HCC) before liver transplantation (LT) remains unclear. Moreover, LRT in the setting of living donor liver transplantation (LDLT) merits further exploration. The objective of the current study was to determine risk factors for poor outcomes after LDLT in patients who received locoregional therapy (LRT). METHODS: We reviewed patients (n = 46) who underwent LDLT after LRT. Multivariate analysis was performed to determine independent predictors of recurrence-free survival (RFS). Risk scores were developed to define prognostic groups. RESULTS: Median tumor size was 3.7 (1.2-12) cm and tumor number was 1 (1-6). Macrovascular invasion was seen in 10/46 (21.7%) patients. There was a significant difference in 5-year RFS with > 3 tumor nodules (P = 0.005), tumors outside University of California San Francisco criteria (P = 0.03), bilobar disease (P = 0.002), AFP > 600 ng/ml (P = 0.006), and poor response to LRT (P = 0.007). On multivariate analysis, bilobar disease (HR = 2.9, P = 0.01), AFP > 600 ng/ml (HR = 2.3 P = 0.008), and poor response to LRT (HR = 2, P = 0.02) were predictors of 5-year RFS. The 5-year RFS in low risk (score = 0), intermediate risk (score = 1-3), and high risk (score = 4-7) groups was 86%, 76%, and 9% (P < 0.0001). There was no recurrence seen in 4/4 (100%) patients with macrovascular invasion in the low-intermediate risk group. The 5-year RFS in the low-intermediate risk group within and outside Milan criteria was 100% and 74% (P = 0.1). CONCLUSIONS: LDLT can provide excellent long-term RFS in patients after preoperative LRT in the low and intermediate risk groups.

First Fenestrated Endovascular Aortic Aneurysm Repair in Pakistan.

Fenestrated grafts form an alternative to open surgery, and are already increasingly being offered as part of the standard spectrum of treatment in developed countries. The past two decades have seen rapid developments in fenestrated endovascular aneurysm repair (fEVAR)/branched (bEVAR) expertise, to the point where the results are striking and can compete with those of conventional surgery. We here report the case of an 82-year male, who was diagnosed with an abdominal aortic aneurysm 10 years ago. Computed tomography showed a large fusiform juxta-renal abdominal aortic aneurysm extending into bilateral common iliac arteries to their bifurcation. Bilateral femoral access was acquired surgically. Fenestrated part of the stent grafted was deployed successfully. Right and left renal arteries and superior mesenteric artery were stented. Celiac artery showed good flow and no stenting was required. Distal stent graft and bilateral iliac grafts were deployed successfully. Follow up computed tomography scan showed 99% patency and no endoleak. Patient remains stable and asymptomatic at 6-month follow-up. To the best of our knowledge, it is the first reported case of successful fEVAR from Pakistan. Key Words: Fenestrated grafts, Abdominal aortic aneurysm, Endovascular.

Endovascular Aortic Repair for Thoracic Aortic Injuries.

Traumatic aortic injury (TAI) or aortic transection is the second most common cause of death after blunt trauma. The conventional management approach towards a thoracic aortic injury is open thoracotomy and surgical repair; however, there is a recent increase in the trend towards the use of endovascular approach in this regard, particularly in the developed countries. We here report the cases of two young healthy male patients presenting in emergency department with thoracic aortic injury, following a road traffic accident (RTA). Thoracic endovascular aortic repair (TEVAR) was planned for both patients, as open repair was risky owing to other systemic injuries. Aortic stent graft was deployed just below the origin of the left subclavian artery in one patient, while it partially covered the left subclavian in the other. End runs showed good position of the graft with perfusion of aortic branches and exclusion of flow to the transection. Both patients had an uneventful recovery with no episodes of cerebrovascular accident (CVA) or paraplegia. Our study gives an insight into the recent trends of endovascular aortic repair (EVAR) becoming the mainstay treatment for TAIs. As far as we know this is the first reported successful case series of thoracic endovascular stent graft deployment for blunt thoracic aortic trauma in Pakistan. We recommend education and further teaching of surgeons to acquire expertise in this novel approach.

High-dose chemotherapy and peripheral hematopoietic stem cell transplantation in relapsed/refractory Hodgkin's lymphoma.

PURPOSE: High-dose chemotherapy (HDCT) and autologous stem cell transplantation (ASCT) is used to treat patients with relapsed Hodgkin's lymphoma. In this retrospective study we report our experience with patients who underwent HDCT and ASCT. METHODS: All patients ≥15 years old with relapsed/refractory Hodgkin's lymphoma who underwent HDCT and ASCT between June 2001 and December 2013 were included. RESULTS: Fifty-four patients were identified. Median age at transplant was 22 years (range 15-49 years); 26 were men and 28 were women. Forty-eight patients (89%) underwent HDCT and ASCT after achieving a radiological response to salvage chemotherapy. The rate of radiological complete response to salvage chemotherapy was 13% and reached 50% within 3 months of ASCT in assessable patients. After a median follow-up of 25 months, 31 patients (57%) were still alive with no evidence of relapse or progression. Median event-free survival (EFS) was 24 months (95% CI 8.7-39.3) and 3-year EFS was 56%. Median overall survival (OS) was not reached and 3-year OS was 82.5%. Bulky mediastinal disease at relapse, hemoglobin level, and number of salvage regimens did not significantly impact EFS in univariate and multivariate analyses. After transplantation there was a trend towards longer EFS (30 vs. 24 months; p = 0.36) in patients with a longer time from the end of first-line treatment until relapse (≥12 vs. <12 months). The 100-day transplant-related mortality was 5.5%. CONCLUSIONS: HDCT and ASCT for relapsed/refractory Hodgkin's lymphoma is safe. Our findings are consistent with published phase III results. Longer follow-up is warranted.