BestFLR Trial: Liver Regeneration at CT before Major Hepatectomies for Liver Cancer-A Randomized Controlled Trial Comparing Portal Vein Embolization with N-Butyl-Cyanoacrylate Plus Iodized Oil versus Polyvinyl Alcohol Particles Plus Coils.

Background In patients with liver cancer, portal vein embolization (PVE) is recommended to promote liver growth before major hepatectomies. However, the optimal embolization strategy has not been established. Purpose To compare liver regeneration as seen at CT in participants with liver cancer, before major hepatectomies, with N-butyl-cyanoacrylate (NBCA) plus iodized oil versus standard polyvinyl alcohol (PVA) particles plus coils, for PVE. Materials and Methods In this single-center, prospective, randomized controlled trial (Best Future Liver Remnant, or BestFLR, trial; International Standard Randomized Controlled Trial Number 16062796), PVE with NBCA plus iodized oil was compared with standard PVE with PVA particles plus coils in participants with liver cancer. Participant recruitment started in November 2017 and ended in March 2020. Participants were randomly assigned to undergo PVE with PVA particles plus coils or PVE with NBCA plus iodized oil. The primary end point was liver growth assessed with CT 14 days and 28 days after PVE. Secondary outcomes included posthepatectomy liver failure, surgical complications, and length of intensive care treatment and hospital stay. The Mann-Whitney U test was used to compare continuous outcomes according to PVE material, whereas the Χ2 test or Fisher exact test was used for categoric variables. Results Sixty participants (mean age, 61 years ± 11 [standard deviation]; 32 men) were assigned to the PVA particles plus coils group (n = 30) or to the NBCA plus iodized oil group (n = 30). Interim analysis revealed faster and superior liver hypertrophy for the NBCA plus iodized oil group versus the PVA particles plus coils group 14 days and 28 days after PVE (absolute hypertrophy of 46% vs 30% [P < .001] and 57% vs 37% [P < .001], respectively). Liver growth for the proposed hepatectomy was achieved in 87% of participants (26 of 30) in the NBCA plus iodized oil group versus 53% of participants (16 of 30) in the PVA particles plus coils group (P = .008) 14 days after PVE. Liver failure occurred in 13% of participants (three of 24) in the NBCA plus iodized oil group and in 27% of participants (six of 22) in the PVA particles plus coils group (P = .27). Conclusion Portal vein embolization with N-butyl-cyanoacrylate plus iodized oil produced greater and faster liver growth as seen at CT in participants with liver cancer, compared with portal vein embolization with polyvinyl alcohol particles plus coils, allowing for earlier surgical intervention. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Arellano in this issue.

Chemoembolization of Hepatocellular Carcinoma with Drug-Eluting Polyethylene Glycol Embolic Agents: Single-Center Retrospective Analysis in 302 Patients.

PURPOSE: To evaluate the efficacy and safety of transarterial chemoembolization with polyethylene glycol (PEG) drug-eluting embolic agents in the treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: A single-center retrospective study of 302 patients (258 men; 85.4%) with HCC treated during a 20-month period was conducted. The mean patient age was 66 years ± 10; 142 (47%) had Barcelona Clinic Liver Cancer stage A disease and 134 had (44.4%) stage B disease; 174 (57.6%) had a single HCC tumor, 65 (21.5%) had 2, and 62 (20.9%) had 3 or more. Mean index tumor size was 36.6 mm ± 24.8. One-month follow-up computed tomography (CT) response per modified Response Evaluation Criteria In Solid Tumors and clinical and biochemical safety were analyzed. Progression-free and overall survival were calculated by Kaplan-Meier method. RESULTS: Median follow-up time was 11.9 months (95% confidence interval, 11.0-13.0 mo). One-month follow-up CT revealed complete response in 179 patients (63.2%), partial response in 63 (22.3%), stable disease in 16 (5.7%), and progressive disease in 25 (8.8%). The most frequent complications were postembolization syndrome in 18 patients (6%), liver abscess in 5 (1.7%), and puncture-site hematoma in 3 (1%). Biochemical toxicities occurred in 57 patients (11.6%). Survival analysis at 12 months showed a progression-free survival rate of 65.9% and overall survival rate of 93.5%. Patients who received transplants showed a 57.7% rate of complete pathologic response. CONCLUSIONS: Chemoembolization with PEG embolic agents for HCC is safe and effective, achieving an objective response rate of 85.5%.

The shading sign: is it exclusive of endometriomas?

OBJECTIVES: To investigate if the shading sign is an exclusive MRI feature of endometriomas or endometrioid tumors, and to analyze its different patterns. METHODS: Three hundred and fourty six women with adnexal masses who underwent 1.5/3-T MRI were included in this retrospective, board-approved study. The shading sign was found in 56 patients, but five cases were excluded due to lack of imaging follow-up or histological correlation. The final sample included 51 women. The type of tumor and the pattern of shading were recorded for each case. RESULTS: Thirty endometriomas and five endometrioid carcinomas were found. The remaining 16 cases corresponded to other benign and malignant tumors. The overall sensitivity, specificity, positive predictive value, and negative predictive value were 73%, 93%, 59%, and 96%, respectively. Restricting the analysis to cystic lesions without solid or fat component, sensitivity, specificity, positive predictive value, and negative predictive value were 73%, 96%, 94%, and 80%. Five shading patterns were identified: layering (15.7%), liquid-liquid level (11.8%), homogenous (45.1%), heterogeneous (11.8%), and focal/multifocal shading within a complex mass (19.6%). No significant correlation was found between these patterns and the type of tumor. CONCLUSIONS: The shading sign is not exclusive of endometriomas or endometrioid tumors. Homogenous shading was the most prevalent pattern in endometriomas and half of the cases with focal/multifocal shading within a complex mass were endometrioid carcinomas.

Transarterial Chemoembolization with Anthracyclines-Loaded Polyethylene Glycol Drug Eluting Microspheres for the Treatment of Hepatocellular Carcinoma: A Pooled Multicentric Analysis of Survival in 580 Patients.

PURPOSE: To evaluate survival, efficacy and safety of transarterial chemoembolization (TACE) in the treatment of patients with hepatocellular carcinoma (HCC), through a pooled analysis of patients with BCLC 0, A and B HCC stages, treated with polyethylene glycol drug eluting microspheres (PEG-DEM) TACE. MATERIALS AND METHODS: Patients from 3 retrospective and 2 prospective registries were included. Overall survival (OS), progression-free survival (PFS), tumour response and safety were evaluated. Multivariate Cox regression analysis was performed to evaluate predictors of OS. RESULTS: A total of 580 patients (72.1% males, mean age 66.9 ± 10.3 years) were included. 43.5% had BCLC A, and 41.0% BCLC B disease stage, and 85.8% were Child-Pugh class A. Complete and partial response (mRECIST or RECIST1.1) were achieved in 60.14% and 27.11% of patients, with overall response and disease control rates of 87.30% and 94.60%, respectively. Median OS was 50.8 months for the total population, and 61.2 and 38.1 months for BCLC 0 + A and BCLC B patients, respectively. Median PFS for the total population, BCLC 0 + A and BCLC B groups was 15.6, 21.6 and 12.7 months, respectively. CONCLUSIONS: This multicentric pooled analysis confirmed efficacy and safety of PEG-DEM TACE, with a median OS of 50.8 months.

Changes of the hepatic subcapsular blood flow in a case of high-grade retroperitoneal liposarcoma: what to expect?

Changes of the hepatic subcapsular blood flow with the early appearance of hypervascularity near the falciform ligament are rare radiologic findings. They present most frequently in cases of superior vena cava (SVC) obstruction and are related to the recruitment of the cavo-mammary-phrenic-hepatic-capsule-portal and the cavo-superficial-umbilical-portal pathways. We present the case of a 52-year-old female patient with an highly aggressive retroperitoneal liposarcoma with SVC obstruction caused by external compression due to a mediastinal metastatic mass. The patient exhibited no symptoms of SVC obstruction due to the collateral cavo-portal pathways.

Retrospective Study of Transjugular Intrahepatic Portosystemic Shunt Placement for Cirrhotic Portal Hypertension.

BACKGROUND AND AIMS: Transjugular intrahepatic portosystemic shunt (TIPS) is used for decompressing clinically significant portal hypertension. The aims of this study were to evaluate clinical outcomes and adverse events associated with this procedure. METHODS: Retrospective single-center study including 78 patients submitted to TIPS placement between January 2015 and November 2018. Follow-up data were missing in 27 patients, and finally 51 patients were included in the study sample. Data collected from individual registries included demographics, comorbidities, laboratory results, complications, and clinical results according to the indication. RESULTS: Average pre-TIPS portosystemic pressure gradient decreased from 18.1 ± 5 to 6 ± 3 mm Hg after TIPS placement. Indications for TIPS were refractory ascites (63%, n = 49), recurrent or uncontrolled variceal bleeding (36%, n = 28), and Budd-Chiari syndrome (1.3%, n = 1). TIPS-related adverse events occurred in 29/51 (56.8%) patients, with hepatic encephalopathy (HE) in 21 (41%) patients, sepsis in 3, liver failure in 2, hemolytic anemia in 1, acute pulmonary edema in 1, and capsular perforation in 1 patient. Mean follow-up was 15.7 ± 15 months. First-month mortality was 11.7% (n = 6) (sepsis, n = 3; acute liver failure, n = 2; and recurrence of variceal bleeding, n = 1) and was significantly higher for patients with Child-Pugh >9 points (p = 0.01), model of end-stage liver disease (MELD) scores >19 (p = 0.02), and for patients with a history of HE before the procedure (p = 0.001). Older age (p = 0.006) and higher levels of creatinine (p = 0.008) were significantly higher in patients developing HE after TIPS. Ascites persisted in 21.2% (7/33 patients) and was more frequent in patients with lower baseline albumin levels (p = 0.003). Recurrent variceal bleeding occurred in 22% (n = 4/18 patients) and was more frequent in patients with lower baseline hemoglobin levels (p = 0.03). CONCLUSION: TIPS is effective in up to 80% of patients presenting with variceal bleeding or refractory ascites. Careful patient selection based on age and HE history may reduce adverse events after TIPS.

INTRODUÇÃO E OBJECTIVOS: O shunt portossistémico transjugular intra-hepático (TIPS) é usado para descompressão de hipertensão portal hepática clinicamente significativa. Os objetivos deste estudo foram avaliar os resultados clínicos e efeitos adversos associados a este procedimento. MÉTODOS: Estudo retrospectivo de centro único, incluindo 78 pacientes submetidos ao procedimento entre Janeiro de 2015 e Novembro de 2018. Os dados de seguimento estavam ausentes em 27 doentes, tendo sido incluidos 51 doentes na análise. Os dados colhidos de registos individuais incluíram dados demográficos, comorbilidades, resultados laboratoriais, complicações e resultados clínicos, de acordo com a indicação. RESULTADOS: O gradiente médio de pressão portossistémica pré-TIPS foi de 18.1 ± 5 mm Hg, quediminuiu para 6 ± 3 mm Hg. Indicações para TIPS foram ascite refratária (65%, n = 33) e hemorragia varicosa recorrente/refratária (35%, n = 18). As complicações relacionadas ao TIPS ocorreram em 29 doentes (56.8%): encefalopatia hepática (EH) em 21 doentes, sépsis (n = 3), insuficiencia hepática (n = 2), anemia hemolítica (n = 1), edema pulmonar agudo (n = 1) e perfuração capsular (n = 1). O seguimento médio foi de 15.7 ± 15 meses. A mortalidade no primeiro mes foi de 11.7% (n = 6) (sépsis, n = 3; insuficiencia hepática aguda, n = 2; recorrência de hemorragia varicosa, n = 1), e foi significativamente mais frequente em doentes com Child-Pugh >9 pontos (p = 0.01), pontuação de MELD >19 pontos (p = 0.02) e história de EH prévia ao procedimento (p = 0.001). Doentes que desenvolveram EH tinha mais frequentemente idade avançada (p = 0.006) e níveis mais elevados de creatinina (p = 0.008). A ascite persistiu em 21.2% (7/33 doentes), mais habitualmente em doentes com níveis mais baixos de albumina basai (p = 0.003). Hemorragia varicosa recorrente ocorreu em 22% (n = 4/18 doentes), em associação com níveis mais baixos de hemoglobina (p = 0.03). CONCLUSÃO: O TIPS é eficaz em 80% dos doentes que apresentam hemorragia varicosa ou ascite refratária. Eventos adversos podem ser reduzidos através da seleção de doentes, com base na idade e história de EH.

Transarterial Embolization of Iatrogenic Cystic Artery Pseudoaneurysm.

Cystic artery pseudoaneurysm (CAP) is a rare entity most often resulting from inflammatory conditions (acute cholecystitis or pancreatitis) or iatrogenic trauma (cholecystectomy). We report the case of a 73-year-old female who presented with abdominal pain and gastrointestinal bleeding after an episode of acute cholecystitis and endoscopic retrograde cholangiopancreatography for choledocolithiasis removal. Computed tomography and angiography revealed a CAP measuring 5 cm. A right hepatic artery transcatheter embolization was performed with glue, excluding the pseudoaneurysm. The next day, the patient underwent open cholecystectomy with ligation of the cystic artery. Later, ischemic hepatitis and abscess developed.

O pseudoaneurisma da artéria cística é uma entidade rara, que pode resultar de patologia inflamatória (colecistite aguda ou pancreatite) ou trauma iatrogénico (colecistectomia). Apresentamos o caso de uma mulher de 73 anos que se apresentou com dor abdominal e hemorragia digestiva após um episódio de colecistite aguda e CPRE para remoção de coledocolitíase. A TC e a angiografia revelaram um pseudoaneurisma da artéria cística com 5 cm. Foi realizada embolização da artéria hepática direita com cola, com exclusão do pseudoaneurisma. No dia seguinte a paciente foi submetida a colecistectomia com ligação da artéria cística. Posteriormente, desenvolveu-se hepatite isquémica e abcesso hepático.

Successful Revascularization has a Significant Impact on Limb Salvage Rate and Wound Healing for Patients with Diabetic Foot Ulcers: Single-Centre Retrospective Analysis with a Multidisciplinary Approach.

PURPOSE: Analyze the impact of endovascular revascularization on major amputation rates and wound healing for patients with diabetic foot ulcers (DFUs). MATERIALS AND METHODS: Single-center retrospective study from 2014-2018 including 314 patients with DFUs submitted to endovascular revascularizations. Group A-patients with a successful endovascular revascularization (n = 285; 90.8%); Group B-patients submitted to a failed attempt of endovascular revascularization (n = 29; 9.2%). Baseline data were not significantly different between the 2 groups (p > 0.05). Both groups were compared regarding: major amputation rates; wound healing, mortality and adverse events. Survival and regression analyses were used. RESULTS: Mean follow-up time was 734.1 ± 610.2 days. Major amputation rates were 3.9% versus 24.1% (p < 0.0001) and complete wound healing was 53.7% versus 20.7% (p < 0.0001) for patients from Group A versus Group B, respectively. Major adverse events were registered in 2 patients (one from each group); minor adverse events included 10 patients from Group A and 2 patients from Group B (p = 0.3654). Major amputation rates were: 3.9% versus 27.5% at 1 year; 4.6% versus 27.5% at 2-5 years for Group A versus Group B, respectively (p < 0.0001). Survival rates were: 87.8% at 1 year; 84.4% at 2 years; and 77.9% at 5 years with no significant differences between groups. Predictors for major amputation included failed revascularization (p < 0.0001), older age (p = 0.0394), prior stroke (0.0018), dialysis (0.0476). Predictors for mortality included older age (p < 0.0001) and coronary artery disease (p = 0.0388). CONCLUSION: Endovascular revascularization for patients with DFUs is safe and has a significant impact on limb salvage and wound healing.

Together We Stand, Divided We Fall: A Multidisciplinary Approach in Complicated Acute Pancreatitis.

Acute pancreatitis (AP) is an inflammatory condition with a mild course in most patients, but 20-30% evolve to single or multiple organ dysfunction and pancreatic/peripancreatic necrosis, with potentially infected collections. In the first weeks of disease, a systemic inflammatory syndrome (SIRS) dominates the clinical setting, and early management decisions in this precocious phase can change the course of the disease. Imaging is crucial in the diagnosis, and since the adoption of the revised Atlanta classification, four different types of pancreatic/peripancreatic collections have been defined. The management of the complicated forms of AP has been defined by several treatment guidelines, and the main indication for intervention is local infection, preferably in walled-off necrosis. Open surgery necrosectomy is associated with a very high rate of morbimortality, giving a place to different multidisciplinary methodologies, emphasizing drainage and necrosectomy techniques in a "step-up" approach starting from mini-invasive endoscopic drainage and moving, if needed, to progressively more invasive techniques, including interventional radiology and mini-invasive surgery. With the advent of several new technologies in the specialties involved, the complicated AP cases which need drainage and necrosectomy benefit from a new era of multidisciplinary cooperation, permitting higher efficacy with lower levels of morbimortality and reducing hospital stay and costs.

Primary fallopian tube carcinoma: review of MR imaging findings.

OBJECTIVES: To review the epidemiological and clinical features of primary fallopian tube carcinoma (PFTC), and to illustrate the spectrum of MRI findings, with pathological confirmation. METHODS: This article reviews the relevant literature on the epidemiological, clinical, and imaging features of primary fallopian tube carcinoma, with pathological confirmation, using illustrations from the authors' teaching files. RESULTS: Primary fallopian tube carcinoma came under focus over the last few years due to its possible role on the pathogenesis of high-grade serous epithelial ovarian and peritoneal cancers. Typical symptoms, together with the presence of some of the most characteristic MRI signs, such as a "sausage-shaped" pelvic mass, hydrosalpinx, and hydrometra, may signal the presence of primary fallopian cancer, and allow the radiologist to report it as a differential diagnosis. CONCLUSIONS: Primary fallopian tube carcinoma has a constellation of clinical symptoms and magnetic resonance imaging features, which may be diagnostic. Although these findings are not present together in the majority of cases, radiologists who are aware of them may include the diagnosis of primary fallopian tube cancer in their report more frequently and with more confidence. TEACHING POINTS: • PFTC may be more frequent than previously thought • PFTC has specific clinical and MRI characteristics • Knowledge of typical PFTC signs enables its inclusion in the differential diagnosis • PFTC is currently staged under the 2013 FIGO system • PFTC is staged collectively with ovarian and peritoneal neoplasms.

Renal cell carcinoma subtype differentiation using single-phase corticomedullary contrast-enhanced CT.

OBJECTIVE: To compare multiphase and single-phase corticomedullary contrast-enhanced computed tomographic (CT) imaging in the differentiation of renal cell carcinoma (RCC) subtype. MATERIAL AND METHODS: Pathology records were reviewed from January 2008 to March 2013. The final cohort consisted of 79 patients (57 men, 22 women; mean age: 64±13). Quantitative tumor percentage enhancement (TE), cortical enhancement, and tumor-to-cortex enhancement (TCI) indexes were calculated. RESULTS: Single-phase evaluations showed significantly lower mean TE and TCI for papillary tumors when compared with clear cell and cromophobe tumors (P<.01). Comparison of receiver operating characteristic curve analyses did not show significant differences between both evaluation methods. CONCLUSION: Accuracy of RCC subtype differentiation with single-phase corticomedullary contrast-enhanced CT is comparable to multiphasic imaging.