Double-Balloon Catheter-Mediated Transarterial Chemotherapy Delivery in a Swine Model: A Mechanism Recruiting the Vasa Vasorum for Localized Therapies.

PURPOSE: Treatment of hypovascular tumors, such as pancreatic adenocarcinoma, is challenging owing to inefficient drug delivery. This report examines the potential mechanism of localized drug delivery via transarterial microperfusion (TAMP) using a proprietary adjustable double-balloon occlusion catheter in a porcine model. MATERIALS AND METHODS: Adult Yorkshire swine (N = 21) were used in the Institutional Animal Care & Use Committee-approved protocols. The RC-120 catheter (RenovoRx, Los Altos, California) was positioned into visceral, femoral, and pulmonary arteries with infusion of methylene blue dye, gemcitabine, or gold nanoparticles. Transmural delivery was compared under double-balloon occlusion with and without side-branch exclusion, single-balloon occlusion, and intravenous delivery. Intra-arterial pressure and vascular histologic changes were assessed. RESULTS: Infusion with double-balloon occlusion and side-branch exclusion provided increased intra-arterial pressure in the isolated segment and enhanced perivascular infusate penetration with minimal vascular injury. Infusates were predominantly found in the vasa vasorum by electron microscopy. CONCLUSIONS: TAMP enhanced transmural passage mediated by localized increase in arterial pressure via vasa vasorum.

Correcting Coagulopathy for Image-Guided Procedures.

Patients with acquired coagulopathy often require percutaneous image-guided invasive procedures for urgent control of hemorrhage or for elective procedures. Routine preprocedural evaluation of coagulopathy previously focused on absolute prothrombin time, partial thromboplastin time, international normalized ratio, and platelet count values. Now viscoelastic testing and greater understanding of patient- and drug-specific changes in coagulation profiles can yield better coagulation profile data. More specific reversal agents and profiles combine for less generalized and more titrated transfusion or correction algorithms. This article reviews procedural and patient-specific factors for defining both hemorrhagic risk and correction strategies.

Hepatic artery pseudoaneurysms and hepatic ischaemic injury: a rare complication of polyarteritis nodosa.

A woman in her 70s presented with months of intermittent fevers, severe fatigue, headaches, abdominal pain and haematuria. She developed acute onset left-sided weakness and was found to have radiographic evidence of right frontal and left parietal intraparenchymal haemorrhages with subarachnoid haemorrhage. She also had markedly elevated liver transaminases with subsequent abdominal MRI that revealed hepatic artery pseudoaneurysms (HAP) requiring embolisation. The case required a multidisciplinary approach consisting of hepatology, interventional radiology and rheumatology. Ultimately, the aetiology was attributed to polyarteritis nodosa (PAN). Through this case report, we highlight HAP as an extremely rare complication of PAN. Although it is a challenging diagnosis to make, it has a favourable response to immunosuppression with high-dose corticosteroids.

Improvement of functional properties of cow's milk peptides through partial proteins hydrolysis.

Allergy by cow's milk proteins is among the major food allergies and could be reduced by the partial hydrolysis of these proteins by proteases, without significantly affecting its physicochemical properties. In addition, the peptides generated through enzymatic hydrolysis of the cow's milk can present prebiotic and bioactive properties. In this work, the cow's milk proteins were submitted to a controlled hydrolysis by Novo-Pro D® and the influence of the degree of hydrolysis (DH) on peptide size distribution was evaluated, as well as the prebiotic and antimicrobial properties of milk hydrolysates. It was shown that for DH-10%, all the peptides have sizes lower than 12 kDa which is the size of the most allergenic proteins, without apparent changes in the milk, as long as heating of the hydrolysate is avoided. The protein hydrolysis promoted a great improvement in the milk functional properties. In addition, the obtained milk peptides presented great prebiotic activities, as indicated by the significant improvement of the growth of prebiotic L. acidophilus and L. reuteri and by the production of bacteriocins indicated by the inhibition halos in the growth of a pathogenic microorganism. Supplementary Information: The online version contains supplementary material available at 10.1007/s13197-022-05533-x.

Pancreatic-Portal Vein Fistula: a Rare Diagnosis with Wide-Ranging Complications-13-Year Experience of a Pancreas Center of Excellence.

PURPOSE: To determine factors affecting mortality, and long-term patency of portal vein, in patients with pancreatic-portal vein fistula (PPVF). METHODS: Consecutive cases of PPVF at the University of Pittsburgh Medical Center from 2008 to 2020 were retrospectively identified. Clinical history, imaging studies, management strategies, complications, and long-term outcomes were analyzed. RESULTS: Fourteen patients, representing the largest PPVF cohort reported to date (mean age 58.6 years, 64.3% women, median follow-up 10 months [1-98 months]) were identified. Underlying chronic pancreatitis was seen in 9 (64.3%) patients, while 5 (35.7%) developed PPVF with first attack of acute pancreatitis. PPVF involved proximal main portal vein (MPV) in 10 (78.6%) patients. Of the 5 patients (35.7%) who died, all had occlusive (n=4) or near-occlusive (n=1) PPVF-associated filling defect (FD) in the MPV. Conversely, 7 of 9 survivors (87.5%) had subocclusive FD and patent MPV. In patients with sepsis (n=5), 1 underwent surgical necrosectomy and survived, while 3 of 4 (75%) patients without debridement died. CONCLUSION: Occlusive/near-occlusive PPVF-associated MPV FD, and sepsis, are associated with high mortality rates, while subocclusive MPV FD is associated with survival and long-term MPV patency. PPVF is a potentially life-threatening, and possibly under-diagnosed, entity that warrants early clinical suspicion for timely diagnosis, to facilitate optimal management.

Enzymatic hydrolysis of black cricket (Gryllus assimilis) proteins positively affects their antioxidant properties.

The development of innovative ingredients through biotechnological routes has established insect proteins as an emerging source of bioactive peptides. The current study aimed to evaluate the antioxidant properties of black cricket (Gryllus assimilis) protein hydrolysates produced using the proteases FlavourzymeTM 500L, AlcalaseTM 2.4L, and NeutraseTM 0.8L, either individually or in binary/ternary combinations. The enzymatic hydrolysis promoted an increase of approximately 160% in total antioxidant capacity and 93% in the ferric reducing antioxidant power. The isolated use of the enzyme FlavourzymeTM 500L showed the most prominent positive effect on the antioxidant properties, presenting an IC50 value of 455 and 71 µg/mL for DPPH and ABTS radicals scavenging activities, respectively. This sample was composed mainly of small peptides (MW < 3 kDa), in which the antioxidant properties increased after fractionation by ultrafiltration. Gel electrophoresis analysis showed protein hydrolysates composed mainly of polypeptide chains with a mass of less than 14 kDa. Finally, the enzymatic treatment proved to be an efficient process to improve the antioxidant properties of black cricket proteins, increasing the possibility of applying these hydrolysates as bioactive ingredients in food or nutraceutical products. PRACTICAL APPLICATION: Insects represent an alternative source of proteins. Their modification through hydrolysis allows for the acquisition of compounds with great potential in industrial applications, such as functional ingredients or for nutraceutical purposes. The use of our experimental design proved to be an adequate tool for defining the best process conditions required for increasing the attainment of biologically active compounds.

The role of interventional radiology in the pre-liver transplant patient.

Each year approximately 8500 patients undergo liver transplantation in the USA for acute and chronic liver failure. Over the years, the success of liver transplantation has led to more clinical indications for liver transplantation. These expanded indications, without a proportionate increase in donors, result in increased competition for the limited pool of transplantable whole or partial grafts. The likelihood of receiving a deceased donor graft depends on many clinical variables, including the acute and chronic fitness of the candidate aligning with the timing of donor organ availability. Several types of patients are candidates for transplant: patients with acute fulminant hepatic failure who will die without a transplant, patients with decompensated cirrhosis, and patients with HCC and compensated cirrhosis. Interventional radiology can preserve equity between these subgroups and reduce patient dropout by increasing the physiologic and anatomic fitness of the candidate before and after formal listing. The primary determinants of candidacy fitness and dropout are the severity of clinical symptoms related to portal hypertension and the presence of hepatocellular cancer. There is a subgroup of patients whose disease severity is not accurately reflected by the Model for End-stage Liver Disease (MELD), such as patients with chronic cholestasis that also may benefit from IR management.

A ten-year, single institution experience with percutaneous nephrostomy during pregnancy.

PURPOSE: To evaluate the safety and efficacy of percutaneous nephrostomy (PCN) in pregnancy. MATERIALS AND METHODS: PCN tubes were placed during 52 pregnancies in 49 patients from 2008 to 2018. The medical records during pregnancies were retrospectively reviewed for imaging findings, procedural parameters, outcomes of delivery, and complications. RESULTS: The mean gestational age on percutaneous nephrostomy placement was 27 weeks (range, 8-36 weeks). PCN catheters were placed for the following indications: 1) flank or lower abdominal pain (42%), 2) obstructing calculi (37%), 3) pyelonephritis (20%), and 4) obstructing endometrioma (2%). Prior to PCN, retrograde ureteric stenting was performed in 17 of 49 patients (34%) and attempted but failed in 4 patients (8%). Nephrostomy drainage relieved pain completely or significantly in all 12 patients without prior ureteral stenting, but in only 4 of 10 with retrograde ureteric stents. In one patient in whom the ureteral stent had been removed, PCN relieved her flank pain. The mean number of PCN catheter exchanges was 1.6, ranging from 0 to 9, with a mean time interval of 21.3 days between exchanges. There were 29 difficult exchanges due to encrustation in 15 patients with a mean of 20.5 days between exchanges. CONCLUSIONS: PCN drainage is a safe and effective treatment for managing symptomatic hydronephrosis in pregnant patients but is less effective in treating pain when retrograde ureteral stents are in place. Rapid encrustation, seen more commonly in pregnancy, tends to recur in the same patients and requires more frequent exchanges than the general population.

Interventional Therapies for Thoracic Duct Injury and Intractable Chylothorax.

Injury to the thoracic duct with resultant chylothorax can cause significant patient morbidity and mortality. Conservative treatment strategies often fail to address the problem. Open surgical and percutaneous approaches are often required to manage patients with refractory chylothorax. This review describes in detail the major role of minimally invasive interventional therapies for thoracic duct (TD) injury. The review emphasizes strategies for identifying the TD on preprocedural imaging and describes various techniques for percutaneous access to the TD. The advantages and disadvantages of several approaches for accessing the duct are discussed. The technique of duct embolization is highlighted. The role of the minimally invasive percutaneous approach over open surgical approaches is discussed with a review of clinical outcomes, as reported in the literature. This review will also briefly discuss the surgical approach to TD ligation.

A proliferating trichilemmal cyst in the perianal region: A case report.

INTRODUCTION: Proliferating trichilemmal cysts (PTCs) are rare benign neoplasms originating from the follicular isthmus. They can undergo trichilemmal keratinization and malignant degeneration to form epidermoid carcinoma. They occur on the scalp in more than 90% of patients and are more common in elderly women. PRESENTATION OF CASE: A 56-year-old woman complained of perianal discomfort upon sitting. She presented with a perianal nodule of approximately 3 cm in diameter that had exhibited slow and progressive growth over 8 years. After surgical excision of the lesion with safety margins, histopathological examination showed that it was a proliferating trichilemmal cyst in the perianal region. DISCUSSION: There are no reports in the literature on PTC in the perianal region. The location with the highest prevalence is the scalp; other sites of occurrence are the neck, trunk, underarms, pubis, vulva, lower and upper limbs, upper lip, and gluteal region. CONCLUSION: The development of PTC in the perianal region is an exceptional occurrence, and when it does occur, surgical treatment should always be indicated because of the risk of malignant degeneration to form epidermoid carcinoma.

Stereotactic Body Radiation Therapy as an Alternative to Transarterial Chemoembolization for Hepatocellular Carcinoma.

PURPOSE: To conduct a large single-institution comparison of transarterial chemoembolization (TACE) and stereotactic body radiation therapy (SBRT) outcomes in similar groups of patients with hepatocellular carcinoma (HCC). METHODS AND MATERIALS: From 2006 to 2014, 209 patients with 1 to 2 tumors underwent TACE (n=84) to 114 tumors or image guided SBRT (n=125) to 173 tumors. Propensity score analysis with inverse probability of treatment weighting was used to compare outcomes between treatments while adjusting for imbalances in treatment assignment. Local control (LC), toxicity, and overall survival (OS) were retrospectively analyzed. RESULTS: The TACE and SBRT groups were similar with respect to the number of tumors treated per patient, underlying liver disease, and baseline liver function. Patients treated with SBRT were older (65 vs 61 years, P=.01), had smaller tumors (2.3 vs 2.9 cm, P<.001), and less frequently underwent liver transplantation (8% vs 18%, P=.01). The 1- and 2-year LC favored SBRT: 97% and 91%, respectively, for SBRT and 47% and 23% for TACE (hazard ratio 66.5, P<.001). For patients treated with TACE, higher alpha-fetoprotein (hazard ratio 1.11 per doubling, P=.008) and segmental portal vein thrombosis (hazard ratio 9.9, P<.001) were associated with worse LC. Predictors associated with LC after SBRT were not identified. Grade 3+ toxicity occurred after 13% and 8% of TACE and SBRT treatments, respectively (P=.05). There was no difference in OS between patients treated with TACE or SBRT. CONCLUSIONS: Stereotactic body radiation therapy is a safe alternative to TACE for 1 to 2 tumors and provides better LC, with no observed difference in OS. Prospective comparative trials of TACE and SBRT are warranted.

Improved quantitative 90 Y bremsstrahlung SPECT/CT reconstruction with Monte Carlo scatter modeling.

PURPOSE: In 90 Y microsphere radioembolization (RE), accurate post-therapy imaging-based dosimetry is important for establishing absorbed dose versus outcome relationships for developing future treatment planning strategies. Additionally, accurately assessing microsphere distributions is important because of concerns for unexpected activity deposition outside the liver. Quantitative 90 Y imaging by either SPECT or PET is challenging. In 90 Y SPECT model based methods are necessary for scatter correction because energy window-based methods are not feasible with the continuous bremsstrahlung energy spectrum. The objective of this work was to implement and evaluate a scatter estimation method for accurate 90 Y bremsstrahlung SPECT/CT imaging. METHODS: Since a fully Monte Carlo (MC) approach to 90 Y SPECT reconstruction is computationally very demanding, in the present study the scatter estimate generated by a MC simulator was combined with an analytical projector in the 3D OS-EM reconstruction model. A single window (105 to 195-keV) was used for both the acquisition and the projector modeling. A liver/lung torso phantom with intrahepatic lesions and low-uptake extrahepatic objects was imaged to evaluate SPECT/CT reconstruction without and with scatter correction. Clinical application was demonstrated by applying the reconstruction approach to five patients treated with RE to determine lesion and normal liver activity concentrations using a (liver) relative calibration. RESULTS: There was convergence of the scatter estimate after just two updates, greatly reducing computational requirements. In the phantom study, compared with reconstruction without scatter correction, with MC scatter modeling there was substantial improvement in activity recovery in intrahepatic lesions (from > 55% to > 86%), normal liver (from 113% to 104%), and lungs (from 227% to 104%) with only a small degradation in noise (13% vs. 17%). Similarly, with scatter modeling contrast improved substantially both visually and in terms of a detectability index, which was especially relevant for the low uptake extrahepatic objects. The trends observed for the phantom were also seen in the patient studies where lesion activity concentrations and lesion-to-liver concentration ratios were lower for SPECT without scatter correction compared with reconstruction with just two MC scatter updates: in eleven lesions the mean uptake was 4.9 vs. 7.1 MBq/mL (P = 0.0547), the mean normal liver uptake was 1.6 vs. 1.5 MBq/mL (P = 0.056) and the mean lesion-to-liver uptake ratio was 2.7 vs. 4.3 (P = 0.0402) for reconstruction without and with scatter correction respectively. CONCLUSIONS: Quantitative accuracy of 90 Y bremsstrahlung imaging can be substantially improved with MC scatter modeling without significant degradation in image noise or intensive computational requirements.

Failure mode and effects analysis in a dual-product microsphere brachytherapy environment.

PURPOSE: We performed a failure mode and effects analysis (FMEA) during the addition of a new microspheres product into our existing microsphere brachytherapy program to identify areas for safety improvements. METHODS AND MATERIALS: A diverse group of team members from the microsphere program participated in the project to create a process map, identify and score failure modes, and discuss programmatic changes to address the highest ranking items. We developed custom severity ranking scales for staff- and institution-related failure modes to encompass possible risks that may exist outside of patient-based effects. RESULTS: Between both types of microsphere products, 173 failure mode/effect pairs were identified: 90 for patients, 35 for staff, and 48 for the institution. The SIR-Spheres program was ranked separately from the TheraSphere program because of significant differences in workflow during dose calculation, preparation, and delivery. High-ranking failure modes in each category were addressed with programmatic changes. CONCLUSIONS: The FMEA aided in identifying potential risk factors in our microsphere program and allowed a theoretically safer and more efficient design of the workflow and quality assurance for both our new SIR-Spheres program and our existing TheraSphere program. As new guidelines are made available, and our experience with the SIR-Spheres program increases, we will update the FMEA as an efficient starting point for future improvements.

The impact of laparoscopic surgery in colorectal cancer resection with respect to the development of liver metastasis in the long-term / Impacto da cirurgia videolaparoscópica em ressecções de câncer colorretal quanto ao desenvolvimento de metástases hepáticas a longo prazo

INTRODUCTION: Colorectal cancer (CRC) shows high incidence and mortality worldwide, particularly in Western and developed countries. The objective of this study is to evaluate the oncologic results during a minimum follow-up of 2 years of curable CRC patients submitted to laparoscopic resection in our environment, regarding to the development of hepatic metastases. METHODS: Medical records of 189 colon and rectal patients with potentially curable adenocarcinoma who have been submitted to laparoscopic resection have been reviewed through a retrospective cohort between January 2005 and March 2012 at a single institution regarded as reference to this type of treatment. Pearson's X² and Long-rank tests have been used for statistical analysis and data was analyzed by statistic package STATA version 11.0. RESULTS: The eligible population for the study was 146 patients, 91 women (62%), with a mean age of 61 ± 13 years. Minimum follow-up was 24 months, having an mean follow-up of 60 ± 27 months and an mean follow-up of global disease recurrence of 27 ± 11 months. Hepatic metastases occurred in 7.5% of the population, most from stage III, and the mean recurrence period was 25 ± 16 months. CONCLUSIONS: Laparoscopic resection for potentially curable CRC in this cohort did not change the long-term incidence of hepatic metastases, considering that our results are comparable to large randomized clinical trial results. Laparoscopic resection was effective and safe for analyzed patients, regarding long-term oncologic results.

INTRODUÇÃO: O câncer colorretal (CCR) apresenta elevada incidência e mortalidade mundial, especialmente nos países ocidentais e desenvolvidos. O objetivo deste estudo é avaliar, durante um seguimento mínimo de 2 anos, pacientes com CCR potencialmente curável submetidos a ressecções laparoscópicas, em relação ao surgimento de metástases hepáticas. MÉTODOS: Através de coorte retrospectiva foram revisados os prontuários de 189 portadores de adenocarcinoma de cólon e reto potencialmente curáveis, submetidos a ressecção laparoscópica entre janeiro de 2005 e março de 2012, numa única instituição considerada de referência neste tipo de tratamento. Para análise estatística foram usados o teste X² de Pearson e o teste Log-rank, e os dados foram analisados pelo pacote estatístico STATA versão 11.0. RESULTADOS: A população elegível do estudo foi de 146 pacientes, sendo 91 mulheres (62%), com idade média de 61 ± 13 anos. O seguimento mínimo foi de 24 meses, sendo o tempo médio de seguimento de 60 ± 27 meses, e o tempo médio de recorrência global da doença de 27 ± 11 meses. Metástases hepáticas ocorreram em 7,5% da população, a maioria proveniente do estadio III, e o tempo médio de recorrência no fígado foi de 25 ± 16 meses. CONCLUSÕES: Para esta coorte a ressecção do CCR potencialmente curável por via laparoscópica não modificou a incidência de metástases hepáticas a longo prazo, ao comparar nossos resultados aos dos grandes ensaios clínicos randomizados. Para os pacientes analisados, a ressecção laparoscópica foi eficaz e segura em relação aos resultados oncológicos a longo prazo.

Novel inexpensive fungi proteases: Production by solid state fermentation and characterization.

A comparative study was carried out for proteases production using agroindustrial residues as substrate for solid state fermentation (SSF) of several fungal strains. High protease production was observed for most of the microorganisms studied, as well as very different biochemical characteristics, including activities at specific temperatures and a wide range of pH values. The enzymes produced were very different regarding optimum pH and they showed stability at 50 °C. Aspergillus oryzae showed stability at all pH values studied. Penicillium roquefortii and Aspergillus flavipes presented optimum activity at temperatures of 50 °C and 90 °C, respectively. Lyophilized protease from A. oryzae reached 1251.60 U/g and yield of 155010.66 U/kg of substrate. Therefore, the substrate as well as the microorganism strain can modify the biochemical character of the enzyme produced. The high protease activity and stability established plus the low cost of substrates, make these fungal proteases potential alternatives for the biotechnological industry.

Sonographic assessment of spleen stiffness before and after transjugular intrahepatic portosystemic shunt placement with or without concurrent embolization of portal systemic collateral veins in patients with cirrhosis and portal hypertension: a feasibility study.

OBJECTIVES: To determine the feasibility of spleen stiffness measurement in the evaluation of portal hemodynamics in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) placement. METHODS: We prospectively correlated the spleen stiffness as measured by the shear wave velocity with the portal pressure and portosystemic gradient in patients undergoing TIPS procedures. Twenty-three consecutive patients referred for placement of a TIPS were enrolled. Included in our study were 19 patients in whom a spleen stiffness measurement was obtained before, immediately after, and 1 to 3 days after placement. Spleen stiffness was measured by calculating the Young modulus estimated from the shear wave velocity. A 2-tailed nonparametric Mann-Whitney U test was used to assess statistically significant differences in spleen stiffness measurement after TIPS placement, and regression analysis was used to correlate spleen stiffness measurement with portal pressure. RESULTS: After TIPS placement, the spleen stiffness measurement increased, with a mean increase in the Young modulus ± SD of 6.54 ± 6.29 kPa in 42% of patients (8 of 19). In the remaining 58% (11 of 19), the spleens became softer after TIPS placement (Young modulus decreased by 9.57 ± 8.82 kPa). Eight patients, including 5 with concurrent embolization or thrombosis of competitive shunts, had increased spleen stiffness. The mean change in the median spleen stiffness before and after TIPS placement between the patients with and without competitive shunts was statistically significantly different (P < .04, nonparametric Mann-Whitney U test). There was no measurable correlation between spleen stiffness measurement and portal pressure before and after TIPS placement. CONCLUSIONS: This study demonstrates the feasibility of a noninvasive spleen stiffness measurement, which could complement conventional sonography with additional functional information in patients undergoing TIPS procedures.

Volumetric blood flow in transjugular intrahepatic portosystemic shunt revision using 3-dimensional Doppler sonography.

OBJECTIVES: Three-dimensional (3D)/4-dimensional (4D) sonographic measurement of blood volume flow in transjugular intrahepatic porto systemic shunt revision with the intention of objective assessment of shunt patency. METHODS: A total of 17 patients were recruited (12 male and 5 female; mean age, 55 years; range, 30-69 years). An ultrasound system equipped with a 2.0-5.0-MHz probe was used to acquire multivolume 3D/4D color Doppler data sets to assess prerevision and postrevision shunt volume flow. Volume flow was computed offline based on the principle of surface integration of Doppler-measured velocity vectors in a lateral-elevational c-surface positioned at the color flow focal depth (range, 8.0-11.5 cm). Volume flow was compared to routine measurements of the prerevision and postrevision portosystemic pressure gradient. Prerevision volume flow was compared with the outcome to determine whether a flow threshold for revision could be defined. RESULTS: Linear regression of data from revised transjugular intrahepatic portosystemic shunt cases showed an inverse correlation between the mean-normalized change in prerevision and postrevision shunt volume flow and the mean-normalized change in the prerevision and postrevision portosystemic pressure gradient (r(2) = 0.51; P = .020). Increased shunt blood flow corresponded to a decreased pressure gradient. Comparison of prerevision flows showed preliminary threshold development at 1534 mL/min, below which a shunt revision may be recommended (P = .21; area under the receiver operating characteristic curve = 0.78). CONCLUSIONS: Shunt volume flow measurement with 3D/4D Doppler sonography provides a potential alternative to standard pulsed wave Doppler metrics as an indicator of shunt function and predictor of revision.

Low dose rate radiosensitization of hepatocellular carcinoma in vitro and in patients.

Transarterial radioembolization (TARE) with (90)Y microspheres delivers low dose rate radiation (LDR) to intrahepatic tumors. In the current study, we examined clonogenic survival, DNA damage, and cell cycle distribution in hepatocellular carcinoma (HCC) cell lines treated with LDR in combination with varying doses and schedules of 5-fluorouracil (5-FU), gemcitabine, and sorafenib. Radiosensitization was seen with 1 to 3 µM 5-FU (enhancement ratio 2.2-13.9) and 30 to 100 nM gemcitabine (enhancement ratio 1.9-2.9) administered 24 hours before LDR (0.26 Gy/h to 4.2 Gy). Sorafenib radiosensitized only at high concentrations (3-10 µM) when administered after LDR. For a given radiation dose, greater enhancement was seen with LDR compared to standard dose rate therapy. Summarizing our clinical experience with low dose rate radiosensitization, 13 patients (5 with HCC, 8 with liver metastases) were treated a total of 16 times with TARE and concurrent gemcitabine. Six partial responses and one complete response were observed with a median time to local failure of 7.1 months for all patients and 9.9 months for patients with HCC. In summary, HCC is sensitized to LDR with clinically achievable concentrations of gemcitabine and 5-FU in vitro. Encouraging responses were seen in a small cohort of patients treated with TARE and concurrent gemcitabine. Future studies are needed to validate the safety and efficacy of this approach.

Preoperative splenic artery embolization in klippel-Trenaunay syndrome with massive splenomegaly: A case report.

The authors describe a case of Klippel-Trenaunay syndrome (KTS) with massive splenomegaly in a 29-year-old woman. Preoperative splenic artery embolization using the "double embolization technique" (a combination of distal selective splenic artery embolization and proximal splenic artery occlusion) facilitated open splenectomy.