90Y-Radioembolization After Failed Portal Vein Embolization for Colorectal Liver Metastases: A Case Report.

The main limiting factor for liver resection is insufficient future liver remnant (FLR). Portal vein embolization (PVE) is a standard of care treatment to induce FLR hypertrophy, but it is not always efficient. Radioembolization (RE) has a potential to induce liver hypertrophy for PVE-refractory patients. However, this was reported only for the patients with hepatocellular carcinoma. We described two cases of lobar RE after PVE failure for the patients with colorectal liver metastases. This enabled to reach sufficient FLR, provide good local disease control and bridge the patients to extended hepatectomy.

Bacterial attachment to oxygen-functionalized graphenic surfaces.

In this work we have investigated the effect of oxygen plasma treatment of graphenic surfaces and the introduction of functional groups on changes in work function, wettability, surface free energy and bacterial adhesion. The plasma parameters were adjusted (generator power: <60 W, exposure time: <20 min) to limit the modifications to the surface without changing the bulk structure. The parent and modified graphenic surfaces were thoroughly characterized by µRaman spectroscopy, thermogravimetry, scanning electron microscopy, contact angle, X-ray photoelectron spectroscopy, work function and microbiological tests. It was found that even the short time of plasma modification results in a significant increase in work function, surface free energy and hydrophilicity. The changes in surface chemistry stimulate also substantial changes in bacterial adhesion. The strong relationship between work function and adhesion of bacteria was observed for all the investigated strains (Staphylococcus epidermidis, Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli) whereas the bacterial colonization trend correlates with the bacterial zeta potential. The bacteria-graphenic surface interaction is discussed in terms of total interaction energy. The results point out the work function lowering of the graphenic biomaterial surface as an effective strategy for the infection risk limitation.

[Utility of early imaging of myocardial innervation scintigraphy in the diagnosis of Lewy Body Dementia]. / Utilidad de la imagen precoz de la gammagrafía de inervación miocárdica en el diagnóstico de la demencia con cuerpos de Lewy.

UNLABELLED: The importance of accurate and early diagnosis of dementia with Lewy bodies (DLB) lies in its pharmacological management. Delayed imaging of cardiac (123)I-MIBG scintigraphy allows differentiation between DLB and other neurodegenerative diseases with cognitive impairment. The aim of this study was to assess the utility of early imaging of cardiac (123)I-MIBG scintigraphy for differentiating DLB from others neurodegenerative disease with cognitive impairment. MATERIAL AND METHODS: We assess retrospectively 106 patients (51 men, mean age 78 years) with cognitive impairment that underwent a cardiac (123)I-MIBG study. Planar images were acquired in anterior view of the thorax 15min (early) and 4h (delayed) after tracer administration. The heart-to-mediastinum ratios (HMR) at 15m (HMR15m) and at 4h (HMR4h) were obtained. RESULTS: After four years, 52 patients were diagnosed of DLB.HMR15m and HMR4h were significantly inferior in DLB respect to the others neurodegenerative diseases (1,27±0,15 vs 1,76±0,15,p<0,05) and (1,14±0,13 vs 1,68±0,19,p<0.01), respectively. The ROC analysis showed a HMR15m cut off point of 1.56 to differentiated DLB from the other dementias with a sensitivity and a specificity of 98%. CONCLUSIONS: Early imaging of cardiac (123)I-MIBG scintigraphy can help to differentiate DLB from other neurodegenerative diseases with cognitive impairment.

PET/CT with [18F] fluorodeoxyglucose in the assessment of metabolic response to neoadjuvant chemotherapy in locally advanced breast cancer.

AIM: The aim of this paper was to prospectively evaluate FDG PET/CT in the assessment of metabolic response to neoadjuvant chemotherapy and correlation with tumor cellularity in locally advanced breast cancer. METHODS: Images were acquired with a PET/CT scanner in 50 patients at baseline and after completion of treatment, just before surgery. All findings were confirmed by histopathological analysis. PET/CT quantification (SUVmax) at baseline and after finishing neoadjuvant chemotherapy (4 cycles of epirubicin + cyclophosphamide +/- taxanes) were compared using RECIST criteria and Miller & Payne (M&P) scale. RESULTS: Baseline mean tumor size was 4.4±1.6 cm. Thirty eight patients were considered responders and 12 nonresponders. According to M&P scale, 10 patients had good prognosis (grades 4-5) and 40 patients had bad prognosis (grades 1-3). All patients with grade 5 M&P had no significant postchemotherapy FDG uptake. Patients with bad prognosis had lower SUVmax variation (∆SUVmax) than patients with good prognosis (60.7% vs. 80.5%, P=0.0016). ∆SUVmax was lower in nonresponders than in partial responders according to RECIST criteria (38.9% vs. 67.6%, p<0.001), and was also lower in partial responders than complete responders (67.6% vs. 85.4%, P=0.005). A cut-off ∆SUVmax value of 52% differentiates responders from nonresponders with a sensitivity of 86% and a specificity of 90%. Probability densities of the ∆SUVmax (%) for stable disease (<45), partial (>45 to <82) and complete response (>82) showed an overall accuracy of 78% (Weighted Kappa=0.74). CONCLUSION: PET/CT is useful to monitor response to neoadjuvant chemotherapy in locally advanced breast cancer. ∆SUVmax on PET/CT correlates with tumor cellularity after completion of neoadjuvant chemotherapy.

Cardiac sympathetic impairment parallels nigrostriatal degeneration in Probable Dementia with Lewy Bodies.

AIM: Dementia with Lewy Bodies (DLB) must be distinguished from other types of dementia because of important differences in patient management and outcome. Both reduction in cardiac 123I-metaiodobenzilguanidine (MIBG) uptake and decreased 123I-FP-CIT binding in basal ganglia have been described in DLB. The aim of this study was to assess the relationship between cardiac sympathetic activity and nigrostriatal degeneration in patients with probable DLB. METHODS: Twenty-eight patients (15 males; mean age 77 years, range 64-88 years) with clinical international criteria of probable DLB were included in the study. All patients underwent a cardiac MIBG scintigraphy and a FP-CIT SPECT. Global cardiac MIBG uptake was semiquantified by means of heart-to-mediastinum ratio (HMR) (normal >1.56). FP-CIT binding in basal ganglia was calculated and compared with an age-matched control group. The relation between cardiac MIBG uptake and FP-CIT uptake in basal ganglia, and the relationship of these two techniques with distinctive symptoms of DLB, features of past medical history and data from the neuropsychological examination were assessed. RESULTS: Cardiac MIBG uptake was decreased in 23 of 28 patients (HMR=1.32, range 0.95-1.85). The FP-CIT binding in basal ganglia was significantly lower than in control group (2.01±0.5 vs 2.62±0.2, P<0.05). All patients with reduced cardiac HMR showed decreased FP-CIT binding in basal ganglia. There was a positive correlation between the HMR and specific binding ratio of striatum (P<0.01). A high correlation between FP-CIT SPECT and the presence of parkinsonism also was found. No correlation between cardiac MIBG uptake and demographic, clinical or neuropsychological data was found. CONCLUSION: In probable DLB cardiac MIBG uptake and FP-CIT binding in basal ganglia are reduced. The positive correlation between both measures suggests that cardiac sympathetic degeneration and nigrostriatal degeneration parallel similarly in patients with probable DLB.

Monitoring system for isolated limb perfusion based on a portable gamma camera.

BACKGROUND: The treatment of malignant melanoma or sarcomas on a limb using extremity perfusion with tumour necrosis factor (TNF-alpha) and melphalan can result in a high degree of systemic toxicity if there is any leakage from the isolated blood territory of the limb into the systemic vascular territory. Leakage is currently controlled by using radiotracers and heavy external probes in a procedure that requires continuous manual calculations. The aim of this work was to develop a light, easily transportable system to monitor limb perfusion leakage by controlling systemic blood pool radioactivity with a portable gamma camera adapted for intraoperative use as an external probe, and to initiate its application in the treatment of MM patients. METHODS: A special collimator was built for maximal sensitivity. Software for acquisition and data processing in real time was developed. After testing the adequacy of the system, it was used to monitor limb perfusion leakage in 16 patients with malignant melanoma to be treated with perfusion of TNF-alpha and melphalan. RESULTS: The field of view of the detector system was 13.8 cm, which is appropriate for the monitoring, since the area to be controlled was the precordial zone. The sensitivity of the system was 257 cps/MBq. When the percentage of leakage reaches 10% the associated absolute error is +/-1%. After a mean follow-up period of 12 months, no patients have shown any significant or lasting side-effects. Partial or complete remission of lesions was seen in 9 out of 16 patients (56%) after HILP with TNF-alpha and melphalan. CONCLUSION: The detector system together with specially developed software provides a suitable automatic continuous monitoring system of any leakage that may occur during limb perfusion. This technique has been successfully implemented in patients for whom perfusion with TNF-alpha and melphalan has been indicated.

Breast cancer therapy: the role of PET-CT in decision making.

This paper describes the role of positron emission tomography (PET) and PET-computed tomography (CT) in breast cancer patients. Fluorine-18-Fluoro-D-glucose (FDG) has limited diagnostic value in detecting small noninvasive primary tumors, in staging the axillary region in early stages and in the detection of osteoblastic metastases. Better results have been shown in the detection and staging of primary invasive tumors. Significant clinical data are available in the monitoring of primary chemotherapy in locally advanced breast cancer where [(18)F]FDG PET-CT allows prediction of the response even shortly after the onset of therapy. Quantitative evaluation of tumor uptake is necessary. Therapy-induced changes in tumor metabolism may be helpful in making decisions about continuation, modification or cessation of therapy. Therefore, [(18)F]FDG PET-CT appears to be a promising tool for the personalization of breast cancer treatment by its early identification of nonresponders. It offers improved patient care, avoiding ineffective chemotherapy and the side effects while reducing the cost. An area generating high expectations for PET-TC in breast cancer is in monitoring in order to tailor therapy to the tumor characteristics of individual patients who may require tracers other than [(18)F]FDG. The introduction of new PET tracers and the development of new instruments will offer opportunities to improve the role of PET-CT in decision making of therapy in these patients.

[Potential use of bone marrow scintigraphy in suspected prosthetic hip infection evaluated with 99mTc-HMPAO-leukocytes]. / Valor de la gammagrafía de médula macrofágica en el diagnóstico de infección de prótesis total de cadera estudiada con leucocitos Tc-HMPAO.

AIM: To evaluate the usefulness of (99m)Tc-Sulphur colloid when combined with leukocyte scintigraphy in suspected prosthetic hip infection, comparing the results with information from (99m)Tc-HMPAO-leukocyte scintigraphy alone. MATERIALS AND METHODS: Seventy patients (42 women, 28 men; mean age 68 +/- 13 years) with painful hip prostheses and suspicion of infection were evaluated prospectively. All patients had bone scintigraphy, (99m)Tc-HMPAO-labelled white blood cell scintigraphy and (99m)Tc-Sulphur colloid bone marrow scintigraphy. ESR and CRP levels were measured in all patients. The final diagnosis was made with microbiological findings or by clinical follow up of at least 12 months. RESULTS: Infections were diagnosed in 12 of the 70 patients (3 coagulase-negative Staphylococcus, 2 Staphylococcus aureus, 2 Staphylococcus epidermidis, 2 enterococcus and 3 polymicrobial agents). ESR and CRP values were higher in patients with infection than in patients without infection (51.8 +/- 29.4 vs. 25.4 +/- 16.4 and 2.8 +/- 2.2 vs. 1.1 +/- 1.3, respectively; p < 0.05). Bone scintigraphy did not show a characteristic pattern to differentiate infection from aseptic loosening. The pool phase of the bone scintigraphy was positive in only 3/12 patients with infection (25 %). Sensitivity and specificity of the leukocyte scintigraphy was 83 % and 57 %, respectively. When the results of the bone marrow scintigraphy were added, these values increased to 92 % and 98 %, respectively. CONCLUSION: Performing bone marrow scintigraphy significantly improves results when compared with leukocyte scintigraphy alone in the diagnosis of infected hip prostheses. Bone scintigraphy did not help to differentiate aseptic loosening from infection in this series.

[Usefulness of 111In-oxine labelled platelets in the management of febrile syndrome in dialysis patients with non-functional renal allografts]. / Utilidad de la gammagrafía con plaquetas marcadas con 111In-oxina en el manejo del síndrome febril en pacientes en diálisis portadores de injerto renal no funcionante.

AIM: To evaluate the usefulness of 111In-oxine-labelled platelet scan in the therapeutic management of prolonged febrile syndrome in dialysis patients with a non-functional renal allograft. MATERIAL AND METHODS: One hundred and fifty-eight patients (94 men, 64 women; mean age 44 +/- 9 years) were studied. Duration of fever was 42 days (range 7-112). A total of 68 % of the patients (107/158) were on low doses of corticosteroids (<10 mg/day). Platelet scans were performed 48 hours after reinjection of 111In-ixone-labelled platelets. A platelet uptake index (PUI) was calculated by dividing the cpm/pixel in the allograft by the cpm/pixel in a mirror background. A PUI > or = 1.5 was considered as threshold for immunological fever. The final diagnosis of immunological fever was established when it disappeared after transplantectomy, embolization or high doses of corticosteroid therapy. Fever of non-immunological origin was established when it disappeared after antibiotic therapy. RESULTS: In 102/158 patients the fever was considered of immunological origin. In 56/158 patients the fever was considered of non immunological origin. Sensitivity and the specificity of the platelet scan was 80 % and 100 %, respectively. All those patients considered as having fever of immunological origin who had PUI <1.5 had been using corticosteroids during platelet scan. CONCLUSION: 111In-labelled platelet scintigraphy is a useful technique in the therapeutic management of prolonged febrile syndrome in dialysis patients with non-functional renal allograft. The use of corticosteroids can reduce the sensitivity of 111In- labelled platelet scan.

Activation of renal signaling pathways in db/db mice with type 2 diabetes.

BACKGROUND: Altered regulation of signaling pathways may contribute to the pathogenesis of renal disease. We examined renal cortical signaling pathways in type 2 diabetes. METHODS: The status of renal cortical signaling pathways was examined in control and db/db mice with type 2 diabetes in the early phase of diabetic nephropathy associated with renal matrix expansion and albuminuria. RESULTS: Tyrosine phosphorylation of renal cortical proteins was increased in diabetic mice. Renal cortical activities of phosphatidylinositol 3-kinase (PI 3-kinase) in antiphosphotyrosine immunoprecipitates, Akt (PKB), and ERK1/2-type mitogen-activated protein (MAP) kinase activities were significantly augmented sixfold (P < 0.01), twofold (P < 0.0003), and sevenfold (P < 0.001), respectively, in diabetic mice compared with controls. A part of the increased renal cortical PI 3-kinase activity was due to insulin receptor activation, as PI 3-kinase activity associated with beta chain of the insulin receptor was increased nearly fourfold (P < 0.0235). Additionally, the kinase activity of the immunoprecipitated insulin receptor beta chain was augmented in the diabetic renal cortex, and tyrosine phosphorylation of the insulin receptor was increased. In the liver, activities of PI 3-kinase in the antiphosphotyrosine immunoprecipitates and Akt also were increased threefold (P < 0.05) and twofold (P < 0.0002), respectively. However, there was no change in the hepatic insulin receptor-associated PI 3-kinase activity. Additionally, the hepatic ERK1/2-type MAP kinase activity was inhibited by nearly 50% (P < 0.01). CONCLUSIONS: These studies demonstrate that a variety of receptor signaling pathways are activated in the renal cortex of mice with type 2 diabetes, and suggest a role for augmented insulin receptor activity in nephropathy of type 2 diabetes.

Successful use of recombinant tissue plasminogen activator in a patient with relapsing peritonitis.

Intraperitoneal (IP) administration of either streptokinase (SK) or urokinase (UK) has assumed an adjunctive role to antibiotic therapy in selected patients with relapsing peritonitis. In these circumstances, bacteria may be protected from antibiotics through sequestration in either fibrinous structures or biofilms within the lumen of the peritoneal dialysis (PD) catheter or the peritoneal cavity. In some cases, it appears that disruption of these sheltered microenvironments by thrombolytic agents facilitated eradication of the offending organism and obviated the need for catheter removal, replacement, or interim hemodialysis. Although IP SK has been generally well tolerated as additive therapy in relapsing peritonitis, sporadic reports of significant complications, such as abdominal pain, fever, and severe hypotension, have precluded its more widespread acceptance. The only other thrombolytic agent used in this setting, UK, is presently unavailable because of a manufacturing shortfall. Therefore, adjunctive thrombolytic therapy for relapsing peritonitis is currently restricted. To circumvent these limitations, we devised an IP tissue plasminogen activator (tPA) protocol to eliminate recurring infection in a patient undergoing chronic ambulatory PD. After a third episode of peritonitis caused by Enterobacter cloacae, treated twice previously with an adequate antibiotic regimen, we instilled 6 mL of tPA (1 mg/mL) into the PD catheter for a 2-hour dwell time. The treatment was well tolerated and, in conjunction with a third course of antibiotic therapy, has produced an infection-free interval of 8 months.