Open abdomen and entero-atmospheric fistulae: An interim analysis from the International Register of Open Abdomen (IROA).

INTRODUCTION: No definitive data describing associations between cases of Open Abdomen (OA) and Entero-atmospheric fistulae (EAF) exist. The World Society of Emergency Surgery (WSES) and the Panamerican Trauma Society (PTS) thus analyzed the International Register of Open Abdomen (IROA) to assess this question. MATERIAL AND METHODS: A prospective analysis of adult patients enrolled in the IROA. RESULTS: Among 649 adult patients with OA 58 (8.9%) developed EAF. Indications for OA were peritonitis (51.2%) and traumatic-injury (16.8%). The most frequently utilized temporary abdominal closure techniques were Commercial-NPWT (46.8%) and Bogotà-bag (21.9%). Mean OA days were 7.9 ± 18.22. Overall mortality rate was 29.7%, with EAF having no impact on mortality. Multivariate analysis associated cancer (p = 0.018), days of OA (p = 0.003) and time to provision-of-nutrition (p = 0.016) with EAF occurrence. CONCLUSION: Entero-atmospheric fistulas are influenced by the duration of open abdomen treatment and by the nutritional status of the patient. Peritonitis, intestinal anastomosis, negative pressure and oral or enteral nutrition were not risk factors for EAF during OA treatment.

Prognostic Evaluation of Vimentin Expression in Correlation with Ki67 and CD44 in Surgically Resected Pancreatic Ductal Adenocarcinoma.

Purpose. Radical surgical resection with adjuvant chemotherapy or chemo-radiotherapy is the most effective treatment for pancreatic ductal adenocarcinoma (PDAC). However, relatively few studies investigate the prognostic significance of biological markers in PDAC. This study aims to look into the expressions of vimentin, Ki67, and CD44 in PDAC surgical specimens and their potential prognostic implications in survival. Method. The study was designed as retrospective, and vimentin, Ki67, and CD44 expressions were evaluated by immunohistochemistry in 53 pancreatic ductal adenocarcinoma cases. Overall survival was assessed by the Kaplan-Meier method. Results. Patients' median age was 68 years. The median survival was 18 months. The tumors were T3-4 in 40/53 (75.5%), and metastases in lymph nodes were found in 42 out of 53 (79.2%) cases. On multivariate analysis, the size of primary tumor (p < 0.001), the surgical resection margin status (p = 0.042), and vimentin expression (p = 0.011) were independently correlated with overall survival. Conclusions. Long-term survival after resection of PDAC is still about 15%. Vimentin expression is a potential independent adverse prognostic molecular marker and should be included in histopathological reports. Also, CD44 expression correlates with high Ki67, vimentin positivity, and N stage and may represent a potential target of novel therapeutic modalities in pancreatic adenocarcinoma patients.

Erratum to: IROA: International Register of Open Abdomen, preliminary results.

[This corrects the article DOI: 10.1186/s13017-017-0123-8.].

IROA: International Register of Open Abdomen, preliminary results.

BACKGROUND: No definitive data about open abdomen (OA) epidemiology and outcomes exist. The World Society of Emergency Surgery (WSES) and the Panamerican Trauma Society (PTS) promoted the International Register of Open Abdomen (IROA). METHODS: A prospective observational cohort study including patients with an OA treatment. Data were recorded on a web platform (Clinical Registers®) through a dedicated website: www.clinicalregisters.org. RESULTS: Four hundred two patients enrolled. Adult patients: 369 patients; Mean age: 57.39±18.37; 56% male; Mean BMI: 36±5.6. OA indication: Peritonitis (48.7%), Trauma (20.5%), Vascular Emergencies/Hemorrhage (9.4%), Ischemia (9.1%), Pancreatitis (4.2%),Post-operative abdominal-compartment-syndrome (3.9%), Others (4.2%). The most adopted Temporary-abdominal-closure systems were the commercial negative pressure ones (44.2%). During OA 38% of patients had complications; among them 10.5% had fistula. Definitive closure: 82.8%; Mortality during treatment: 17.2%. Mean duration of OA: 5.39(±4.83) days; Mean number of dressing changes: 0.88(±0.88). After-closure complications: (49.5%) and Mortality: (9%). No significant associations among TACT, indications, mortality, complications and fistula. A linear correlationexists between days of OA and complications (Pearson linear correlation = 0.326 p<0.0001) and with the fistula development (Pearson = 0.146 p= 0.016). Pediatric patients: 33 patients. Mean age: 5.91±(3.68) years; 60% male. Mortality: 3.4%; Complications: 44.8%; Fistula: 3.4%. Mean duration of OA: 3.22(±3.09) days. CONCLUSION: Temporary abdominal closure is reliable and safe. The different techniques account for different results according to the different indications. In peritonitis commercial negative pressure temporary closure seems to improve results. In trauma skin-closure and Bogotà-bag seem to improve results. TRIAL REGISTRATION: ClinicalTrials.gov NCT02382770.

Treatment of urethral strictures with balloon dilation: A forgotten tale.

Urethral stricture is a common condition that can lead to serious complications such as urinary infections and renal insufficiency secondary to urinary retention. Treatment options include catheterization and dilation, urethroplasty and endoscopic internal urethrotomy as well. Although treatment option depends on the type, length and aetiology of stricture, the choice can be influenced to varying degrees by the simplicity of the method, the preferences of the patient the available accoutrements and the patient health condition. Both urethroplasty and endoscopic internal urethrotomy require anaesthesia and thus are not suitable for many elder and unfit for surgical treatment patients. On the other hand, dilations are easy to perform in every day clinical practice however they have been associated with iatrogenic urethral trauma. In contrast, balloon dilation under vision dilates by radial application of forces against the stricture, avoiding the potentially shearing forces associated with sequential rigid dilation. Since it reduces the possibility of an iatrogenic urethral trauma and the subsequent spongiofibrosis may lead into improved therapeutic outcomes. In this report we describe a technique for the treatment of urethral strictures with balloon dilation in elder and unfit for surgical treatment patients.

Attenuation of Oxidative Stress by Ischemic Preconditioning in an Experimental Model of Intraabdominal Hypertension.

PURPOSE: Increased intra-abdominal pressure, as used in laparoscopic surgery or seen in intraabdominal hypertension (IAH), is associated with tissue ischemia and oxidative stress. Ischemic preconditioning (IP) is a method successfully used in liver and transplant surgery, in order to attenuate the detrimental effects of ischemia and reperfusion. In this experimental study, we tested the ability of IP to modify oxidative stress induced by extremely high intraabdominal pressures. METHODS: Twenty-five female pigs were studied and divided in three groups: a control group, a pneumoperitoneum group (with pressure of 30 mmHg), and an ischemic preconditioning group (initially subjected to preconditioning with pressure of 25 mmHg for 15 min and desufflation for 15 min and then to pneumoperitoneum as in pneumoperitoneum group). Blood samples were obtained at identical time intervals in the three groups. Total oxidative capacity, total antioxidative capacity and total nitric oxide (NO), nitrite and nitrate concentrations were measured and compared between groups. RESULTS: IP increased total antioxidative capacity (p = .045) and protective mediators like nitrite (p = .022). It was also associated with a trend toward lower levels of total oxidative capacity at the end of the abdominal desufflation period but statistical significance was not met. CONCLUSIONS: IP attenuated oxidative stress induced by IAH, mainly by increasing antioxidative capacity and the levels of protective mediators. The fact that IP was effective, even when used at extremely high levels of intraabdominal pressure, reinforces the interest on this method but further studies are needed to clarify its mechanism of action and potential clinical applications.

Necrotizing soft tissue infection of the right anterolateral abdominal wall caused by a ruptured gangrenous appendix in an elderly diabetic patient.

Necrotizing soft tissue infections (NSTIs) of the abdominal wall usually occur when either a common superficial soft tissue infection progresses down to, or an injury (e.g. knife stab) penetrates, the investing muscle fascia, or an intra-abdominal infection spreads directly to the muscle layers of the abdominal wall. These infections are severe and associated with significant morbidity and mortality. We present an 83-year-old female diabetic patient who was admitted to the surgical emergency department complaining of right abdominal pain after a fall to the floor. She had previously received oral antibiotics for a minor superficial skin infection attributed to her subcutaneous use of insulin. On admission she exhibited signs of agitation and dyspnoea with hypotension and tachycardia (systolic arterial pressure 90mmHg, heart rate >110 bpm, oxygen saturation 88%). Furthermore, she had a tender right abdomen but without any demonstrable pathology on her skin or crepitus. Arterial blood gases revealed metabolic acidosis and hypoxaemia. An abdominal computed tomography (CT) scan demonstrated signs of infection of the entire right anterior abdominal wall and the LRINEC score was calculated to be 13. Subsequent operative aggressive necrosectomy of all the involved layers of the right anterolateral abdominal wall sparing the peritoneum was undertaken. Unfortunately, the patient died the next day due to multiple organ failure.

A study of Smad4 and Smad7 expression in surgically resected samples of gastric adenocarcinoma and their correlation with clinicopathological parameters and patient survival.

PURPOSE: The canonical signaling pathway for the transforming growth factor-beta (TGF-ß) family is through the Smad proteins which are pivotal intracellular mediators of TGF-ß family members. Recently, disruption of the TGF-ß pathway in cancer has been demonstrated at the level of the Smad signal transducers. In this study, we examined Smad4 and Smad7 expression in gastric carcinomas to elucidate their role in tumor progression. METHODS: The immunohistochemical expression of Smad4 and Smad7 was evaluated in 151 surgically resected samples of gastric adenocarcinoma in order to examine their correlation with clinicopathologic findings and patients' survival. RESULTS: Smad4 and Smad7 expression (low, moderate or strong) was observed in 86.7% (131/151) and 33.1% (50/151) of gastric adenocarcinoma tumor samples, respectively. Our results revealed that the loss of Smad4 expression correlated significantly with the intestinal type, male sex, depth of tumor and poor survival. Smad7 expression was significantly more frequent in intestinal type and well differentiated gastric adenocarcinomas and significantly correlated with the duration of disease-free survival. CONCLUSION: Smad signal transducers are considered as important molecules in tumor development and progression and the evaluation of their expression in human gastric cancer could be useful in selecting stage I patients who should be considered as candidates for adjuvant chemotherapy.

Chemoembolization of hepatocellular carcinoma with HepaSphere 30-60 µm. Safety and efficacy study.

BACKGROUND: This study examined the safety, pharmacokinetics, and efficacy of transarterial chemoembolization of hepatocellular carcinoma (HCC) using a newly developed size of a superabsorbent polymer drug-eluting embolic material. METHODS: Forty-five patients with documented HCC (Child-Pugh score A/B: 55.5 %/44.5 %) were embolized with HepaSphere microspheres 30-60 µm with escalation of lesion, dose, and frequency of re-embolization. Local response was evaluated with modified response evaluation criteria in solid tumors (mRECIST). Plasma levels of doxorubicin were measured in 24 patients at baseline and at 5, 20, 40, 60, and 120 min, at 6, 24, and 48 h, and at 7 days, respectively, to determine doxorubicin in plasma (Cmax) and area under the curve (AUC). Measurements of three patients who underwent lipiodol-based conventional chemoembolization (c-TACE) were also performed. RESULTS: TACE with HepaSphere was well tolerated with an acceptable safety profile and no 30-day mortality. Response rates were calculated on intention-to-treat basis with complete response (CR) in 17.8 % reaching 22.2 % for the target lesion. Overall partial response (PR) was seen in 51.1 %, stable disease in 20 %, and progressive disease in 11.1 % of patients. Overall objective response (CR + PR), including patients treated at all dosages of doxorubicin, was seen in 68.9 % of cases. After a median follow-up of 15.6 months, 1-year survival is 100 %. Doxorubicin AUC was significantly lower in patients with HepaSphere 30-60 µm (35,195 ± 27,873 ng × min/ml) than in patients with conventional TACE (103,960 ± 16,652 ng × min/ml; p = 0.009). Cmax was also significantly lower with HepaSphere 30-60 µm (83.9 ± 32.1 ng/ml) compared with c-TACE (761.3 ± 58.8 ng/ml; p = 0.002). CONCLUSION: HepaSphere 30-60 µm is an effective drug-eluting embolic material with a favourable pharmacokinetic profile.

Vacuum-assisted therapy accelerates wound healing in necrotizing soft tissue infections: our experience in two intravenous drug abuse patients.

Negative pressure wound therapy using vacuum-assisted closure (VAC) devices is currently a well established technique for managing complicated wounds. Such wounds occur after aggressive surgical debridement for necrotizing soft tissue infections (NSTI). In this report we present our experience in two intravenous drug abusers managed with VAC for NSTIs. The patients were 25 and 34 years old, HCV positive and presented with oedema of the upper femoral compartments and concomitant severe sepsis. Ultrasonography and computed tomography revealed severe cellulitis, fluid collection and necrosis of the affected fasciae and muscles. After emergent and subsequent aggressive surgical debridement during the first 48h, the VAC device was applied. Both patients had an uncomplicated postoperative course and a fast recovery from their multiorgan dysfunction. Suture closure of the wounds was achieved at the 25th and 38th postoperative days respectively and patients were discharged without any motor deficit. Negative pressure wound therapy is a modern therapeutic modality for treating complicated infected wounds. Moreover, it accelerates wound healing and primary closure, facilitating patient ambulation and recovery. A dedicated medical and nursing team is an important prerequisite for a successful outcome.

Multiple synchronous primary neoplasms of the breast, colon and rectum after surgery for endometrial cancer: A case report.

INTRODUCTION: Endometrial cancer survivors exhibit an increased incidence of subsequent neoplasms. PRESENTATION OF CASE: We present a patient with a history of endometrial cancer who, 3 years after surgery and radiotherapy, developed synchronous neoplasms of the breast, colon and rectum. The patient underwent abdominoperineal resection, a limited right colectomy, and excision of the breast tumour and axillary lymph node dissection. 18 months after surgery, there has been no disease recurrence. DISCUSSION: Multiple primary malignancies represent 16% of new cancer diagnoses. Research on subsequent malignancies after endometrial cancer has shown an increase in risk in colorectal, urinary bladder, lung and breast primaries. CONCLUSION: This case report illustrates the need for physicians to be aware of and counsel patients on the risk of subsequent cancers on endometrial cancer survivors.

Nonepiphyseal giant cell tumor of the rib: a case report.

A case of a 32-year-old female patient with a giant cell tumor originating in the middle part of the left 10th rib is presented. On X-rays and CT, the tumor caused a well-defined osteolysis with nonsclerotic borders. On MRI, it exhibited intermediate signal intensity on T1 sequences and central high signal and peripheral intermediate signal on T2 sequences. On contrast-enhanced MR images both central and peripheral-periosteal enhancement was noted. Thanks to its small size (2 × 1.3 cm), the lesion was easily resected en bloc with a part of the affected rib. The patient is free of recurrence for 3 years after the operation.

Hepatocellular carcinoma treated with transarterial chemoembolization: Evaluation with parametric contrast-enhanced ultrasonography.

AIM: To evaluate the response of hepatocellular carcinoma (HCC) to transarterial chemoembolization (TACE) using a simplified protocol of parametric contrast-enhanced ultrasound (pCEUS). METHODS: Eighteen patients with HCC (18 target tumors, diameter: 2.8-12 cm) were evaluated before, and 20 d after TACE. The distribution and morphology of TACE-induced necrosis in these tumors precluded accurate evaluation by visual assessment or by simple measurements. For pCEUS, a 4.8 mL bolus of SonoVue (Bracco, Milan, Italy) was intravenously administered and analysis of tumor perfusion during the initial phase of enhancement (0-30 s post injection) was performed with dedicated software (Qontrast, Bracco, Milan, Italy). Time-intensity curves were plotted and three parameters were calculated: peak intensity (PI, in percentage %), time to peak (TTP in seconds, s) and area under the curve during wash-in (AUC-WI, in arbitrary units, a.u). Magnetic resonance imaging was the standard imaging modality for post-treatment evaluation. Changes in tumor size were recorded and response was assessed according to response evaluation criteria in solid tumors criteria. RESULTS: A statistically significant decrease in PI and AUC-WI was observed in the treated tumors post TACE; PIpre: 21.5% ± 8.7% (mean ± SD), PIpost: 12.7% ± 6.7%, P < 0.001, AUC-WI pre: 17493 ± 9563 a.u, AUC-WI post: 9585 ± 5494 a.u, P < 0.001. A slight increase in TTP was noted post TACE, but this was not statistically significant; TTP pre: 13.1 ± 4.3 s, TTP post: 13.6 ± 4.2 s , P = 0.058). The changes in the aforementioned parameters were not accompanied by significant tumor shrinkage. CONCLUSION: pCEUS, even when limited to the study of the arterial phase of tumoral enhancement, can detect and quantify early perfusional changes in HCC post TACE.

Acute suppurative parotitis: a dreadful complication in elderly surgical patients.

BACKGROUND: Acute suppurative parotitis (ASP) is a severe infection seen particularly in elderly surgical patients. Factors that increase the risk of ASP include post-operative dehydration, debilitating conditions, and immunosuppressed states. METHOD: Case report and literature review. RESULTS: An 82-year-old female patient was admitted because of paralytic ileus, dehydration, and poor oral hygiene, and was in distress. After two days of hospitalization, the patient developed a progressive painful swelling of her right parotid gland and fever up to 39.0°C. Computed tomography scanning showed an abscess in the parotid gland. Because of her progressive clinical deterioration, the patient underwent operative drainage of the abscess and removal of the necrotic material. Unfortunately, she suffered multiple organ dysfunction syndrome and died. CONCLUSION: Acute suppurative parotitis requires prompt aggressive treatment that nevertheless may fail.

The impact of ischemic preconditioning on hemodynamic, biochemical and inflammatory alterations induced by intra-abdominal hypertension: an experimental study in a porcine model.

PURPOSE: Intra-abdominal hypertension (IAH) has several pathophysiologic implications on human organs and systems. The aim of this experimental study was to investigate whether ischemic preconditioning (IP), namely the application of IAH for a small period of time prior to establish pneumoperitoneum, can attenuate the hemodynamic, biochemical and inflammatory alterations observed during IAH. METHODS: Twenty-four pigs were divided into three groups: group A (control group), group B (pneumoperitoneum of 30 mmHg) and group C (ischemic preconditioning, consisting of pneumoperitoneum of 25 mmHg for 15 min and subsequent pneumoperitoneum of 30 mmHg). Hemodynamic (central venous pressure, cardiac index, mean arterial pressure, heart rate, stroke volume index, systemic vascular resistance index, global end-diastolic index, intrathoracic blood index and extravascular lung water index), biochemical (serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvate transaminase (SGPT), alkaline phosphatase (ALP), γ-glutamyl transpeptidase (γ-GT), urea and creatinine) and inflammatory (tumour necrosis factor-α, interleukin (IL)-6, IL-10 and C-reactive protein) parameters were measured. RESULTS: (a) Hemodynamics: The increase of central venous pressure monitoring and heart rate and the decrease of cardiac index, mean arterial pressure, stroke volume index, global end-diastolic volume index and intrathoracic blood volume index with the establishment of pneumoperitoneum were attenuated by IP. Systemic vascular resistance index and extravascular lung water were not affected. (b) Urea significantly increased with the pneumoperitoneum. IP, however, attenuated this effect. Οther biochemical parameters (SGOT, SGPT, ALP, γ-GT and creatinine) had a similar upward trend during IAH, which was reversed with IP. (c) Inflammatory parameters: CRP was increased with pneumoperitoneum, an effect that was attenuated with the application of IP. Νo significant differences were observed for interleukins. CONCLUSIONS: Ischemic preconditioning seems to attenuate the pathophysiologic alterations of several hemodynamic, biochemical and inflammatory parameters observed during IAH.

Chemoembolization with doxorubicin-eluting beads for unresectable hepatocellular carcinoma: five-year survival analysis.

PURPOSE: The purpose of this study was to report on the 5-year survival of hepatocellular carcinoma (HCC) patients treated with DC Bead loaded with doxorubicin (DEB-DOX) in a scheduled scheme in up to three treatments and thereafter on demand. MATERIALS AND METHODS: 173 HCC patients not suitable for curable treatments were prospectively enrolled (mean age 70.4 ± 7.4 years). Child-Pugh (Child) class was A/B (102/71 [59/41 %]), Okuda stage was 0/1/2 (91/61/19 [53.2/35.7/11.1 %]), and mean lesion diameter was 7.6 ± 2.1 cm. Lesion morphology was one dominant ≤5 cm (22 %), one dominant >5 cm (41.6 %), multifocal ≤5 (26 %), and multifocal >5 (10.4 %). RESULTS: Overall survival at 1, 2, 3, 4, and 5 years was 93.6, 83.8, 62, 41.04, and 22.5 %, with higher rates achieved in Child class A compared with Child class B patients (95, 88.2, 61.7, 45, and 29.4 % vs. 91.5, 75, 50.7, 35.2, and 12.8 %). Mean overall survival was 43.8 months (range 1.2-64.8). Cumulative survival was better for Child class A compared with Child class B patients (p = 0.029). For patients with dominant lesions ≤5 cm 1-, 2-, 3-, 4-, and 5-year survival rates were 100, 95.2, 71.4, 66.6, and 47.6 % for Child class A and 94.1, 88.2, 58.8, 41.2, 29.4, and 23.5 % for Child class B patients. Regarding DEB-DOX treatment, multivariate analysis identified number of lesions (p = 0.033), lesion vascularity (p < 0.0001), initially achieved complete response (p < 0.0001), and objective response (p = 0.046) as significant and independent determinants of 5-year survival. CONCLUSION: DEB-DOX results, with high rates of 5-year survival for patients, not amenable to curative treatments. Number of lesions, lesion vascularity, and local response were significant independent determinants of 5-year survival.

Colon cancer perforation presenting as a strangulating ventral hernia.

Colorectal cancer remains the second leading cause of death from malignant disease. Despite improvements in the treatment modalities offered to patients, more than half of the operated patients die from the disease. The most common presenting symptoms of colonic carcinoma are changes in bowel habits, bleeding, abdominal pain, abdominal mass, stools mixed with mucus or not, weight loss, anorexia, and other characteristics related to metastasis. Here, the case of a 74-year-old female patient with colon cancer perforation presenting as a strangulating ventral hernia and a mini-review of the current literature are presented.

Post embolization syndrome in doxorubicin eluting chemoembolization with DC bead.

BACKGROUND/AIMS: The investigation of post embolization syndrome (PES) in patients with hepatocellular carcinoma (HCC) after treatment with doxorubicin loaded DC Bead (DEB-DOX). METHODOLOGY: The study included 237 patients treated with sequential DEB-TACE performed at set time intervals every two months until 3 sessions/6 month f-u. Patients were ECOG 0-1, Child-Stage-A (n=116, 48.9%) and B (n=121, 51%). Embolizations were as selective as possible with DC Bead of 100-300µm in diameter followed by 300-500µm loaded with doxorubicin at 37.5mg/mL of hydrated bead (max:150mg). RESULTS: PES regardless of severity was observed in up to 86.5%. However grade 2 PES ranged between 25% and 42.19% across treatments. Temperatures above 38°C were seen in 22.7% to 38.3% across treatments. No statistically significant increase of PES was seen in beads of 100-300µm in diameter; incidence of fever and pain presented correlation with the extent of embolization (p=0.0001-0.006 across treatments). Baseline tumor diameter was associated with incidence of fever (p=0.0001-0.001). Duration of fever correlated with the extent of embolization (p=0.008). PES was not associated with elevation of liver enzymes and was correlated with degree of necrosis (p<0.001). CONCLUSIONS: PES after DEB-DOX represents tumor response to treatment and does not represent collateral healthy liver damage.

Contrast-enhanced ultrasonography with intraarterial administration of SonoVue for guidance of transarterial chemoembolization: an initial experience.

AIMS: To describe the technique and to evaluate the feasibility of contrast-enhanced ultrasound with intraarterial administration of echo-enhancer (i.a CEUS) as a method for guidance of transarterial chemoembolization (TACE). PATIENTS AND METHODS: Twelve patients with 17 target liver tumors underwent superselective TACE, guided with i.a CEUS. After microcatheter placement in a (sub)segmental artery suspected as a tumor feeder, a diluted suspension of SonoVue was injected through the microcatheter, and imaging of the target tumor was performed with a low mechanical index technique and with contrast-specific software. If intraarterial injection of SonoVue was associated with immediate, strong tumoral enhancement, the injected artery was considered as tumor-feeding and TACE was performed, otherwise another artery was evaluated. RESULTS: From 25 segmental or subsegmental arteries evaluated i.a CEUS confirmed that 16 arteries were actually tumor feeders and unequivocal excluding 4 arteries as a tumor arterial supply. The remainder 5 arterial branches could not be safely characterized due to artifacts or technical limitations. In 8 patients in which tumoral vascular supply could not be elucidated by angiography alone, i.a CEUS increased the accuracy of supereselective embolization, and provided other clinically relevant information in 2 of these patients. No adverse effects were observed. CONCLUSIONS: For guidance of superselective TACE i.a CEUS is a safe and feasible method..

Angiofibroma of the spermatic cord: a case report and a review of the literature.

INTRODUCTION: Cellular angiofibroma is a benign vascular neoplasm that typically arises in the paratesticular region in men and is easily confused with inguinal or scrotal hernia. CASE PRESENTATION: We present a case of a cellular angiofibroma arising from the spermatic cord of a 74-year-old Caucasian man. Initially, the lesion was confused with a scrotal hernia, but imaging revealed a subcutaneous, inhomogeneous, but well-circumscribed lesion to the surrounding tissues with rich vasculature. Surgical resection of the lesion was performed. Histology revealed a benign tumor of vascular origin rich in fibroblasts. CONCLUSIONS: Angiofibroma can easily be confused with an inguinal hernia and should be differentiated from Schwann cell tumors, perineuromas, spindle-cell lipomas, aggressive angiomyxomas, angiomyofibroblastomas, solitary fibrous tumors, spindle-cell liposarcomas, and leiomyomas. A safe initial diagnosis is difficult because of its location, nature, and correlation with other structures of the area.