Pneumatosis intestinalis and spontaneous perforation associated with drug toxicity in oncologic patients: a case series.

Pneumatosis Intestinalis (PI) is a rare radiological finding defined as the presence of extra-luminal gas within the intestinal wall. Several anti-tumor drugs can induce a damage of the gastrointestinal walls as an adverse effect, causing loss of mucosal integrity and endoluminal gas diffusion, responsible for PI development. We retrospectively analyzed 8 cases of PI detected through radiological imaging in oncologic patients undergoing various therapeutic regimens: five patients were receiving chemotherapy, two molecular targeted therapy (MTT) and one immunotherapy. Three patients were asymptomatic and pneumatosis was incidentally detected at routinary follow-up CT and then treated conservatively. Five patients presented acute abdomen symptoms and in these cases bowel perforation was the cause of death. Our experience confirms PI and perforation as rare complications of drug toxicity, especially in oncologic patients treated with combinations of different anticancer drugs and documented the second reported case of PI associated with atezolizumab and alectinib single administration.

False in Name Only-Gastroduodenal Artery Pseudoaneurysm in a Recurrently Bleeding Patient: Case Report and Literature Review.

Although the diagnosis of visceral pseudoaneurysm is unusual, it requires emergent attention due to the risk of rupture. We describe a 70-year-old man with a gastroduodenal artery pseudoaneurysm that manifested as recurrent hemorrhage. We highlight the possible etiologies, clinical presentations, diagnostic tools, and treatment options for this condition. In this instance, the patient was successfully treated by selective angioembolization. A visceral pseudoaneurysm should be considered in patients with abdominal pain and GI hemorrhage. At present, angioembolization is a first-line therapy.

What is the best fruit juice to use as a negative oral contrast agent in magnetic resonance cholangiopancreatography?

AIM: To identify, in vitro, the best fruit juice to use as oral contrast agent in magnetic resonance cholangiopancreatography (MRCP) and to test, in vivo, the best natural juice and the new parameters in MRCP sequences identified in vitro. MATERIALS AND METHODS: The in vitro evaluations consisted of measuring the T2 values of a pure solution of manganese (Mn) and iron (Fe) at different concentrations, measuring the content of Mn and Fe in five commercial juices and their T2 relaxation times, and identifying the optimal juice dilution for suppressing the gastrointestinal fluid signal. The new parameters of MRCP sequences were tested in vivo. RESULTS: Manganese alone strongly influenced the shortening of the T2 values (p=0.004). The T2 value with an echo time (TE) of ≥1,000 ms enabled sufficient intestinal fluid suppression in the case of high juice dilution. A flip angle of 90° maximised the differences between the high signal from static fluids, such as the bile and the fluid in the gastrointestinal tract, using fast imaging employing steady-state acquisition (FIESTA) sequences (p<0.001). CONCLUSION: The shortening of the T2 relaxation time depended only on the Mn concentration. All the commercial juices had an Mn concentration sufficient to suppress the gastrointestinal fluid signal using long TE sequences. The oral ingestion of commercial juice before MRCP was enough to suppress the signal from the gastrointestinal fluids, regardless of its dilution after ingestion. When using FIESTA sequences, a flip angle of 90° allowed the best suppression of gastrointestinal fluid signals.

Randomised controlled trial of doxorubicin-eluting beads vs conventional chemoembolisation for hepatocellular carcinoma.

BACKGROUND: Transcatheter arterial chemoembolisation (TACE) is the treatment of choice for intermediate stage hepatocellular carcinoma (HCC). Doxorubicin-loaded drug-eluting beads (DEB)-TACE is expected to improve the performance of conventional TACE (cTACE). The aim of this study was to compare DEB-TACE with cTACE in terms of time-to-tumour progression (TTP), adverse events (AEs), and 2-year survival. METHODS: Patients were randomised one-to-one to undergo cTACE or DEB-TACE and followed-up for at least 2 years or until death. Transcatheter arterial chemoembolisation was repeated 'on-demand'. RESULTS: We enrolled 177 patients: 89 underwent DEB-TACE and 88 cTACE. The median number of procedures was 2 in each arm, and the in-hospital stay was 3 and 4 days, respectively (P=0.323). No differences were found in local and overall tumour response. The median TTP was 9 months in both arms. The AE incidence and severity did not differ between the arms, except for post-procedural pain, more frequent and severe after cTACE (P<0.001). The 1- and 2-year survival rates were 86.2% and 56.8% after DEB-TACE and 83.5% and 55.4% after cTACE (P=0.949). Eastern Cooperative Oncology Group (ECOG), serum albumin, and tumour number independently predicted survival (P<0.05). CONCLUSIONS: The DEB-TACE and the cTACE are equally effective and safe, with the only advantage of DEB-TACE being less post-procedural abdominal pain.

Impact of gadoxetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance on the non-invasive diagnosis of small hepatocellular carcinoma: a prospective study.

BACKGROUND: Gadoxetic acid (Gd-EOB-DTPA) is a 'hepatocyte-specific' contrast agent for magnetic resonance (MR) in both the vascular and the hepatobiliary phases. AIM: To evaluate the contribution of the hepatobiliary phase of Gd-EOB-DTPA MR in the diagnosis of small hepatocellular carcinoma (HCC) in cirrhotic patients under surveillance. METHODS: Between 2008 and 2011, 48 consecutive small (10-30 mm) liver nodules were detected in 33 patients, who prospectively underwent contrast-enhanced ultrasound (CEUS), Gd-EOB-DTPA-enhanced MR and helical-computed tomography (CT) in a blind study. The diagnosis of HCC was established according to AASLD 2005 criteria. RESULTS: Of the 48 nodules, 38 (79%) were diagnosed as HCC, 24 (63%) of them based on AASLD non-invasive criteria, 11 diagnosed at histology and 3 during follow-up. The typical vascular pattern (arterial hypervascularisation and venous/late washout) was detected in 30 (79%) HCC nodules by MR, in 22 (58%) by CT and in 17 (45%) by CEUS. Hypointensity during the MR hepatobiliary phase was observed in all HCC nodules and in 3 nonmalignant nodules (sensitivity 100%, specificity 70%, positive predictive value 93%, negative predictive value 100%, positive likelihood ratio 3.33, negative likelihood ratio 0). Eight (21%) of the 38 HCC nodules, 7 of which lacked the typical vascular features at any of the imaging modalities, showed washout in the portal/venous phase and hypointensity in the hepatobiliary phase at MRI, while this pattern was not detected in any nonmalignant lesion. CONCLUSIONS: Gadoxetic acid magnetic resonance may enhance the sensitivity of the non-invasive diagnosis of small hepatocellular carcinoma nodules in cirrhotic patients under surveillance. Double hypointensity in the portal/venous and hepatobiliary phases could be considered a new magnetic resonance pattern, highly suggestive of hypovascular hepatocellular carcinoma.

Response rate and clinical outcome of HCC after first and repeated cTACE performed "on demand".

BACKGROUND & AIMS: Aim of the study was to assess the clinical impact of conventional transarterial chemoembolization (cTACE) repeated "on demand" on HCC outcome. Outcome measures were: response rate to first and repeated cTACE, recurrence rates and overall survival. METHODS: The outcome of 151 consecutive HCC patients submitted to a first cTACE from January 2004 to December 2005 was retrospectively analyzed. RESULTS: Complete radiological response (CR) was observed in 72/151 (48%), 34/60 (52%) and 12/22 (55%) patients after first, second and third cTACE, respectively. Recurrence rates at 6 and 12months were 37% and 61% after the first cTACE, and 40% and 59% after the second cTACE, respectively. Patients not achieving CR or with a recurrence after CR not treated with curative therapies were 94 and 84 after first and second cTACE, respectively. Of these, 60/94 (64%) and 22/84 (26%) were submitted to a second and third cTACE, respectively. Median overall survival was 32.0months but 25.0months excluding transplanted patients. Factors at the time of first cTACE associated with overall shorter survival at multivariate analysis were higher bilirubin, higher AFP and not achieving CR. CONCLUSIONS: CR and recurrence rates after first and second cTACE were similar. About 64% of patients were submitted to second cTACE, while only few patients (26%) were submitted to third cTACE using an "on demand" policy. These figures may be also useful for planning trials for the evaluation of the efficacy of repeated TACE vs. TACE combined with adjuvant treatments or vs. systemic treatments.

Interventional techniques in the treatment of aortic dissection.

Acute aortic dissection continues to be one of the most catastrophic cardiovascular events. While there is a general consensus on immediate surgical repair when the ascending aorta is involved, the optimal treatment strategy for type B aortic dissection (B-AD) remains controversial. Recently, endovascular treatment with percutaneous stent-graft implantation, originally used for aortic aneurysm exclusion, has acquired an important role in the treatment of B-AD. Imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI) and angiography have a fundamental role in the search for the anatomic details necessary to tailor the stent graft and in evaluating the most suitable anatomy for stent graft. Transesophageal echocardiography is fundamental during the procedure to monitor the correct release of the stent graft and evaluate the result of the procedure expressed by immediate thrombosis out of the stent-graft. Again, imaging techniques, more notably CT, have a fundamental role in the postoperative followup after stent-graft placement. The risk of endoleaks may compromise the result of endovascular repair and increase the risk of aortic rupture. Several reports and a few trials attesting to technical feasibility and safety of stent-graft implantation procedures for B-AD have been reported so far. Also, a randomised trial comparing type B aortic stent-graft placement with medical therapy is currently underway. According to the investigators, new therapeutic indications are likely to emerge also in uncomplicated B-AD.

Unresectable hilar cholangiocarcinoma: multimodality approach with percutaneous treatment associated with radiotherapy and chemotherapy.

Klatskin-type cholangiocarcinoma is a rare tumor, bearing a very poor prognosis: at diagnosis, most patients can only undergo palliation. Evaluation of outcome, mean survival and quality of life was performed in patients with unresectable hilar cholangiocarcinoma treated with multimodality approach in comparison with surgical palliation, biliary stenting or brachytherapy alone. Twenty-six patients with hilar cholangiocarcinoma were studied: 16 patients were enrolled in the multimodality protocol (bilateral biliary drainage; Iridium-192 brachytherapy; plastic endoprosthesis or metallic stent positioning and external radiotherapy plus systemic chemotherapy), 5 patients underwent surgical palliation and 5 percutaneous decompression alone. Nine patients completed the protocol and 7 were treated with brachytherapy followed by biliary stenting alone. The multimodality approach obtained mean survival (10 months) similar to that for surgery and higher than that of the brachytherapy and metallic stenting groups (6 and 2.75 months, respectively). The average hospital stay (15 days) was lower than that of the surgical group (20 days). A multimodality approach is a suitable alternative to palliative surgery of unresectable hilar cholangiocarcinoma.

Post infarction ventricular septal defect. Review of 41 surgical cases.

Forty-one patients with ventricular septal rupture after myocardial infarction were operated over about a 4-year period. The "early" group included 17 patients operated upon within the first 24 hours and 13 of them died. A total of 29 patients were operated within the first week and 21 died. The other 12 were operated after the first week since the diagnosis was made and 11 (92%) survived. The most relevant risk factors were: cardiogenic shock, hypertension and diabetes. The initial management was based on digitalis, diuretics, inotropes (dopamine, dobutamine) and the intra-aortic balloon pump. There was no significant difference in mortality between those patients with associated procedures and those without them, except in those cases of coronary grafts with infartectomy, whose mortality was higher. Early surgical repair of ventricular septal rupture implies a very high mortality (72%), which is even worse when the operation is performed within the first 24 hours (76%).