Focal laser ablation as clinical treatment of prostate cancer: report from a Delphi consensus project.

PURPOSE: To define the role of focal laser ablation (FLA) as clinical treatment of prostate cancer (PCa) using the Delphi consensus method. METHODS: A panel of international experts in the field of focal therapy (FT) in PCa conducted a collaborative consensus project using the Delphi method. Experts were invited to online questionnaires focusing on patient selection and treatment of PCa with FLA during four subsequent rounds. After each round, outcomes were displayed, and questionnaires were modified based on the comments provided by panelists. Results were finalized and discussed during face-to-face meetings. RESULTS: Thirty-seven experts agreed to participate, and consensus was achieved on 39/43 topics. Clinically significant PCa (csPCa) was defined as any volume Grade Group 2 [Gleason score (GS) 3+4]. Focal therapy was specified as treatment of all csPCa and can be considered primary treatment as an alternative to radical treatment in carefully selected patients. In patients with intermediate-risk PCa (GS 3+4) as well as patients with MRI-visible and biopsy-confirmed local recurrence, FLA is optimal for targeted ablation of a specific magnetic resonance imaging (MRI)-visible focus. However, FLA should not be applied to candidates for active surveillance and close follow-up is required. Suitability for FLA is based on tumor volume, location to vital structures, GS, MRI-visibility, and biopsy confirmation. CONCLUSION: Focal laser ablation is a promising technique for treatment of clinically localized PCa and should ideally be performed within approved clinical trials. So far, only few studies have reported on FLA and further validation with longer follow-up is mandatory before widespread clinical implementation is justified.

Preoperative chemoembolization in patients with hepatocellular carcinoma undergoing liver transplantation: influence of emergent versus elective procedures on patient survival and tumor recurrence rate.

Our purpose was to compare the recurrence rate and survival in patients with hepatocellular carcinoma (HCC) who had elective transarterial chemoembolization (TACE), immediate preoperative TACE, or no treatment prior to orthotopic liver transplantation (OLT). A total of 132 patients with HCC had TACE prior to OLT. Eighteen patients had no TACE before OLT and functioned as a control group. The urgent group included 35 patients embolized less than 24 h before OLT and the elective group included 97 patients embolized greater than 1 day before transplantation. These groups were compared with regard to tumor staging, hepatic synthetic function, and post-TACE tumor necrosis and survival and recurrence rates. Patients were followed for a mean of 780 days post OLT (1-2912 days). The tumor staging was similar between groups but the Childs-Pugh score in the urgent and untreated group was significantly higher than that of the other groups. The degree of necrosis at explant was also significantly different between the two treated groups, with an average 35% necrosis in the patients embolized less than 24 h before OLT vs 77% in the elective group (p < 0.002). Recurrence rate in the urgent group was 8 of 35 (23%) in a median of 580 days, 20 of 97 (21%) in a median of 539 days in the elective group, and 2 of 18 (11%) in a median of 331 days in the no-TACE group. Survival at 1, 3, and 5 years was 91%, 80%, and 72% in the elective group, 79%, 58%, and 39% in the urgent group, and 69%, 61%, and 41% in the no-TACE group, respectively. The urgent and no-TACE groups had significantly worse survival compared with the other groups; however, the tumor recurrence rates were statistically the same among all three groups. TACE within 24 h of OLT causes an average of 35% necrosis and elective TACE increases necrosis further to 77%. Despite this difference, the tumor recurrence rate in the three groups is equivalent and no different from that in the group that received no treatment before OLT. The decreased survival in the immediate and no-TACE groups was due to non-cancer-related deaths.

Transition from film to electronic media in the first-year medical school gross anatomy lab.

For the benefit of the first-year gross anatomy students, we digitized and published on a Web site images that had been collected over a 30-year period. We provided a CD-ROM (compact disk, read-only media) containing the image set in higher quality format to students and faculty. We supplemented basic images with hot topics such as CT angiography, virtual colonography, computer-aided diagnosis, and 3D post-processing. Full motion video and moving JPEG (Joint Photo Expert Group) animations were integrated into the atlas. On the post course questionnaire medical students reported that the images on CD-ROM were helpful during the course and for review prior to examinations. Faculty and medical students used the CD-ROM for problem-based learning sections and facilitator training. The images were clear and easily projected during review sessions and were useful for the small group sessions, where they served as examples of normal anatomy.

Hepatic perfusion before and after the transjugular intrahepatic portosystemic shunt procedure: impact on survival.

PURPOSE: This study correlates transjugular intrahepatic portosystemic shunt (TIPS) mortality with flow patterns in the cirrhotic liver. MATERIALS AND METHODS: Twenty-seven TIPS patients and 10 control subjects were used for this study. The authors evaluated hepatic perfusion with venous injections of Tc-99m pertechnetate before and after TIPS. Hepatic time-activity curves were analyzed for type and amount of liver perfusion. These parameters were correlated with survival for a mean follow-up of 18 months. RESULTS: The mean arterial contribution to liver blood flow was 25.4% in the normal control patients, 39.9% in patients prior to TIPS, and increased to 48.3% after TIPS. Although the proportion of arterial supply to the cirrhotic liver varied widely, TIPS mortality did not correlate with the preprocedure hepatic artery/portal venous perfusion ratio. However, patients with both an "arterialized" flow pattern and low total hepatic perfusion had higher mortality, with a mean survival of 2 months compared to patients with a more favorable perfusion profile (mean survival, 28.4 months). CONCLUSIONS: The proportion of arterial perfusion to the liver before TIPS did not affect survival. However, patients with a combination of reduced total hepatic perfusion and an arterial flow pattern had poorer survival, suggesting that both the quantity and quality of hepatic perfusion predicts TIPS outcome.

Portal venous thrombosis: percutaneous therapy and outcome.

PURPOSE: To study the efficacy of percutaneous treatment for portal vein thrombosis (PVT). MATERIALS AND METHODS: Of 20 patients who were evaluated for symptomatic portal occlusion, 14 were successfully treated with use of percutaneous techniques. In patients with noncavernomatous PVT (n = 15), the initial treatment was to increase portal output by creating a transjugular intrahepatic portosystemic shunt (TIPS), which was successful in 12 cases. Methods to decrease arterial input to the portal system (hepatosplenic arterial embolization) were used as primary therapy in two patients and in an additional two patients with continued symptoms, despite a functioning TIPS. RESULTS: All TIPS survivors had patent shunts, although patients with complete PVT required more frequent revisions compared to patients with nonocclusive PVT. Hepatosplenic arterial embolization controlled symptoms in the four patients who were treated, but both patients with patent TIPS died of liver failure after embolization. Of the 14 patients treated, eight died at a mean of 6.2 months (six from hepatoma). CONCLUSION: TIPS is effective in patients with noncavernomatous PVT, although patients with complete thrombosis experience recurrent shunt occlusions and also may develop hepatoma. If TIPS fails, or if symptoms recur, hepatosplenic arterial embolization may be an option.

Interventional radiology of the biliary tract.

Interventional radiology provides a range of management options applicable to a broad spectrum of patients with biliary tract disorders. This review highlights the importance of these procedures, and illustrates their safety and effectiveness. Percutaneous transcatheter decompression has a well-established role in the management of patients with benign and malignant biliary obstruction. The advent of metallic stents has greatly increased the value of these techniques. Patients with biliary tract calculi can be successfully treated with a variety of percutaneous techniques, obviating surgery and providing a useful alternative to endoscopic methods. Finally, percutaneous cholecystostomy has evolved as a valuable adjunct in the treatment of calculous cholecystitis, as well as providing the definitive cure for many patients with acalculous cholecystitis.

Percutaneous radiologic drainage of pancreatic abscesses.

OBJECTIVE: The purpose of our study was to review and report the patient selection, techniques, and results of percutaneous drainage of pancreatic abscesses by retrospective review. MATERIALS AND METHODS: Fifty-nine patients (46 men and 13 women) with a mean age of 44 years old had 80 pancreatic abscesses that were drained percutaneously under radiologic guidance (CT, n = 77; sonography, n = 2; and fluoroscopy, n = 1). Abscesses had a wide spectrum of causes, with alcoholic pancreatitis being most common, trauma second most common, and gallstones third. Ten patients had undergone surgery for pancreatic necrosis or abscess. Patients with pancreatic pseudocysts, necrosis, or acute fluid collections were excluded from this study. RESULTS: Of the 59 patients, 51 (86%) were cured with percutaneous drainage and antibiotic therapy. Of the patients who were not cured with percutaneous drainage, seven required surgery and one underwent repeat percutaneous drainage. In the 59 patients, complications included non-life-threatening bleeding in three patients. Ten of 59 patients (17%) had fistulas that spontaneously formed into the gastrointestinal tract. The duration of catheterization ranged from 4 to 119 days, with a mean duration of 33 days. The rate of mortality at 30 days after completion of percutaneous drainage was 8% (5 of 59). CONCLUSION: Percutaneous drainage was an effective therapy for this defined group of patients with pancreatic abscesses. Factors leading to the relatively high success rate described in this study likely included selection of patients; catheters of adequate size, number, and location; careful follow-up with appropriate catheter manipulations; and an integrated, cooperative approach whereby surgeons were willing to permit drainage to effect its benefits, rather than operating prematurely.

Percutaneous tamponade of inadvertent transthoracic catheterization of the aorta.

During routine placement of a subclavian central venous catheter for cancer chemotherapy, a sheath was inadvertently placed into the aortic arch, through the left lung. We describe a technique for transthoracic compression of the aortic injury using the sheath in conjunction with an occlusion balloon catheter.

Quantification of intrahepatic portosystemic shunting after placement of a transjugular intrahepatic portosystemic shunt.

PURPOSE: To quantify portosystemic shunting and hepatic portal perfusion after placement of a transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHODS: Technetium-99m macroaggregated albumin (MAA) was injected directly into the portal veins of nine asymptomatic patients 3 months after TIPS placement. Portosystemic shunting was quantified by comparing counts in the lungs with those in the liver. One cirrhotic patient and one healthy patient who received portal MAA injections were used as controls. RESULTS: No portosystemic shunting was found in the healthy patient. In the cirrhotic control patient, 77% of the injected activity was in the lungs. Patients with portosystemic shunts had even more activity in the lungs. Even stenotic shunts diverted greater than 80% of portal blood flow systemically. Flow through the TIPS ranged from 84% to 100% (average, 93%); these fractions of flow correlated inversely with portosystemic pressure gradients. CONCLUSION: Cirrhotic livers may divert much of the portal blood systemically before TIPS placement. Afterward, this proportion rises, and most portal flow is diverted into the pulmonary circulation.

Antegrade balloon dilation of postoperative ureterovesical junction obstruction in children.

Obstruction of the ureterovesical junction is an uncommon but well-recognized complication of ureteral reimplantation that traditionally has been treated by surgical correction [1, 5-9]. We report our experience with antegrade balloon dilation (ABD) of these strictures in two children. Obstruction was confirmed by diuretic renogram and pressure perfusion studies prior to ABD. Clinical follow-up was done at 3 months and 14 months, and ultrasonographic studies revealed resolution of the hydronephrosis. In addition, diuretic renograms showed complete washout of radiotracer. Morbidity was limited to episodes of pyelonephritis that readily responded to medical management. ABD of ureteral strictures is a relatively simple procedure with a potential for a high success rate and low morbidity. This modality should be considered as the first line of treatment in patients with distal ureteral obstruction after reimplantation.

Diffuse ileal conduit stenosis from Crohn's disease.

A case of Crohn's disease affecting an ileal loop urinary conduit presented as a diffuse loop stenosis and bilateral hydronephrosis. Radiologic appearance and histology are analyzed to differentiate this unusual complication from other causes of conduit stricture.