Yttrium-90 radioembolization for the treatment of unresectable hepatocellular carcinoma in patients with transjugular intrahepatic portosystemic shunts.

PURPOSE: To evaluate the toxicity and response to radioembolization with yttrium-90 ((90)Y) glass microspheres in patients with hepatocellular carcinoma (HCC) and existing transjugular intrahepatic portosystemic shunts (TIPS). MATERIALS AND METHODS: For treatment of unresectable HCC, 12 patients with a patent TIPS underwent a total of 21 infusions of (90)Y. Toxicity within 90 days of treatment was assessed according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE v4.0). Imaging response within the index lesion was assessed using the World Health Organization (WHO) and European Association for the Study of the Liver (EASL) guidelines. Survival was calculated using the Kaplan-Meier method. RESULTS: All patients had a patent TIPS on imaging before treatment. Clinical toxicities included fatigue (83%), encephalopathy (33%), and abdominal pain (25%). Three patients (25%) experienced new grade 3 or 4 bilirubin toxicity. Imaging response was achieved in 50% and 67% of patients according to WHO and EASL criteria. Six patients (50%) went on to liver transplantation. Median survival censored for liver transplantation was 498 days (95% confidence interval [CI],100-800 d), and uncensored median survival was 827 days (95% CI, 250-2,400 d). CONCLUSIONS: (90)Y radioembolization may be a safe and effective treatment for patients with unresectable HCC and existing TIPS. This minimally embolic therapy may be particularly useful as a bridge to curative liver transplantation.

Association of kyphosis and spinal skeletal abnormalities with intrathoracic stomach: a link toward understanding its pathogenesis.

BACKGROUND: Modern-day concepts about the pathogenesis of an intrathoracic stomach include crural diaphragm muscular deterioration, loss of phrenoesophageal ligament integrity, and presence of abdominothoracic pressure gradients. The role of spinal abnormalities has received little attention. Based on clinical observation, we hypothesized that kyphosis and other spinal diseases are components of the pathophysiology of an intrathoracic stomach. STUDY DESIGN: The study population consisted of 98 patients (men, n = 22; women, n = 76; mean age 69.4 years) undergoing operations for type III or IV hiatal hernia with an intrathoracic stomach. Twenty-four age- and gender-matched control patients without hiatal hernia undergoing pulmonary or pleural procedures were used for comparison. Chest radiographs were assessed for spinal abnormalities, including degree of kyphosis, measured from superior T4 to inferior T12 (modified Cobb method), spinal fractures, osteoporosis, and scoliosis. Statistical analyses included two-sample t-test and Fisher's exact test. RESULTS: Patients with intrathoracic stomach had a greater degree of kyphosis than control patients (Cobb angle, 50.2 degrees versus 39.7 degrees; p < 0.001). This difference was most pronounced in women (Cobb angle, 51.7 degrees versus 40.4 degrees; p < 0.001), although the difference in men was not significant (Cobb angle, 45.0 degrees versus 38.1 degrees; p = 0.25). Patients with an intrathoracic stomach had significantly more vertebral fractures (37 of 98 [38%] versus 3 of 24 [13%]; p < 0.05). There was no difference in prevalence of degenerative changes (51 of 98 [52%], versus 13 of 24 [54%]), osteopenia (30 of 98 [31%] versus 6 of 24 [25%]), and scoliosis (27 of 98 [28%] versus 6 of 24 [25%]). CONCLUSION: Patients with an intrathoracic stomach have a higher degree of kyphosis and more vertebral fractures than age- and gender-matched controls. These data suggest that change in spinal curvature can be important in the pathogenesis of the intrathoracic stomach, a growing problem of our aging population.

Syntheses of alpha- and beta-C-glucopyranosyl serines from a common intermediate.

A versatile synthesis leading to either C-linked alpha- or beta-glucopyranosyl serines is presented from a common, advanced synthetic intermediate. Cyclization of the penultimate carbinol onto the alkene and methanolysis of the lactone yields selectively the alpha-linkage. A transposition of these last steps leads to the beta-linked isomer selectively.

The use of robotically assisted surgery for treating urachal anomalies.

OBJECTIVE: To report the management of urachal anomalies using a robotically assisted approach. PATIENTS AND METHODS: Between January 2005 and February 2006, five patients (mean age 51 years, range 24-68) were diagnosed with urachal anomalies. Two basic robot-assisted surgical approaches were used for excising the urachal anomalies: excision of the urachal remnant via partial cystectomy, and radical cystectomy for excision of urachal adenocarcinoma. RESULTS: All five cases were successful and the excised specimens were assessed histologically. The short-term oncological outcome in the three patients with histologically confirmed moderately differentiated adenocarcinoma showed no evidence of recurrent disease within a median interval of 8 months. Surveillance follow-up cystoscopy in the patients who had a partial cystectomy showed a well-healed bladder mucosa with no evidence of recurrence. CONCLUSIONS: Radical excision of the urachal tract with partial cystectomy or radical cystectomy using the da Vinci robot is safe, effective and technically feasible.