Three-dimensional visualized technology-guided surgical resection for giant hepatic hemangioma with hemorrhagic necrosis: A case report and literature review.

Background: Hepatic hemangioma is the most common type of benign mesenchymal liver tumor and often has a good prognosis. However, giant hepatic hemangioma larger than 10 cm is an unusual event, and accompanying symptoms of internal hemorrhagic necrosis are extremely rare. There are only a few cases reported. Case summary: Herein, we report the case of a 52-year-old man with hemorrhagic necrosis of a giant hepatic hemangioma. The patient presented to the Department of Hepatobiliary Surgery with a complaint of distending pain on the right abdomen. The patient underwent hepatic artery embolization for giant hepatic hemangioma 2 weeks before presentation. During hospitalization, abdominal computed tomography revealed a mass (15.8 × 14.2 × 14.7 cm) with high density below the right lobe of the liver. The patient subsequently underwent irregular right hepatectomy with the guidance of three-dimensional visualization technology. The surgical anatomy confirmed the diagnosis of internal hemorrhagic necrosis. There was no recurrence or complications in a 4-month follow-up. Previous cases were reviewed to characterize the clinical features of giant hepatic hemangioma with internal hemorrhage necrosis. Conclusion: Cases of giant hepatic hemangioma with internal hemorrhagic necrosis are rare and usually only exhibit fever or epigastric pain. All patients in reviewed cases finally underwent surgical resection. Under these circumstances, the healing effect of transhepatic arterial treatment is not very satisfactory. Patients are deemed poor laparoscopic surgical candidates due to limited abdominal cavity. In order to standardize the diagnosis of these rare cares, the aggregation of existing and future case data is certainly warranted. If diagnosed, consideration should be given to implementing surgical resection according to patients' condition by three-dimensional visualized technology.

The incidence and predictive factors of secondary epilepsy in patients with supratentorial brain metastases (st-BMs) after stereotactic radiosurgery: A multicenter retrospective study.

OBJECTIVE: To evaluate the incidence and the independent risk factors of SRS-related epilepsy in patients with supratentorial brain metastases (st-BMs), providing evidences for prevention or reduction secondary epilepsy after SRS. METHODS: Patients with st-BMs from four gamma knife centers who developed secondary epilepsy after SRS were retrospectively studied between January 1, 2017 and June 31, 2023. The incidence and clinical characteristics of the patients with secondary epilepsy were analyzed. The predictive role of baseline clinical-demographic variables was evaluated according to univariate and multivariate logistic regression model. The impact of secondary epilepsy on patients' OS was evaluated as well by log-rank test. RESULTS: 11.3 % (126/1120) of the patients with totally 158 st-BMs experienced secondary epilepsy after SRS in median 21 days. 61.9 % (78/126) of the patients experienced simple partial seizures. 91.3 % (115/126) patients achieved good seizure control after received 1-2 kinds of AEDs for median 90 days, while 7.1 % (9/126) of the patients suffered from refractory epilepsy. Patients had higher risk of secondary epilepsy if the tumor located in cortex and/or hippocampus, peri-tumor edema larger than 20.3 cm3 before SRS, had epilepsy history, and failed to receive bevacizumab prior to SRS. There was no difference in the OS of patients who experience secondary epilepsy or not after SRS. CONCLUSIONS: The incidence of SRS-related secondary epilepsy is 11.3 % in patients with st-BMs in this retrospective study. The risk of secondary epilepsy is higher in patients with st-BM located in cortex and/or hippocampus area, peri-tumor edema larger than 20.3 cm3 before SRS, and epilepsy history. Bevacizumab is suggested prior to SRS therapy, as it could be used for the control of peri-tumor edema and SRS-related damage, hence reduce the risk of secondary epilepsy. However, whether or not patients suffered from secondary epilepsy after SRS does not affect their OS.

Outcomes of 2-SSRS plus bevacizumab therapy strategy for brainstem metastases (BSM) over 2 cm3: a multi-center study.

Despite 2-staged stereotactic radiosurgery (2-SSRS) has been reported to provide patients with improved survival and limited toxicity, 2-SSRS for brainstem metastases (BSM) larger than 2 cm3 remains challenging. We tried to find out the effectiveness and safety of 2-SSRS plus bevacizumab therapy for BSMs over 2 cm3 and prognostic factors that related to the tumor local control. Patients that received 2-SSRS plus bevacizumab therapy from four gamma knife center were retrospectively studied from Jan 2014 to December 2023. Patients' domestic characteristics and the tumor features were evaluated before and after the treatment. Cox regression model was used to find out prognostic factors for tumor local control. 53 patients with 63 lesions received the therapy. The median peri-tumor edema volume greatly reduced at the end of therapy (P < 0.01), the median tumor volume dramatically reduced (P < 0.01) and patients' KPS score improved significantly (P < 0.05) 3 months after the therapy. Patients' median OS was 12.8 months. The tumor local control rate at 3, 6, and 12 months was 98.4%, 93.4%, and 85.2%. The incidence side effects were mainly oral and nasal hemorrhage (5.7%, 3/53), and radiation necrosis (13.2%, 7/53). Patients with primary lung adenocarcinoma, therapeutic dose over 12 Gy at second-stage SRS, primary peri-tumor edema volume less than 2.3 cm³, primary tumor volume less than 3.7 cm³ would enjoy longer tumor local control. These results suggested that 2-SSRS plus bevacizumab therapy was effective and safe for BSMs over 2 cm3. However, it is important for patients with BSM to receive early diagnosis and treatment to achieve good tumor local control.

Multi-institutional study of 'Sandwich treatment' for motor area large brain metastases (LBM) with diameter over 3 cm.

BACKGROUND: The objective of the present study was to explore the effectiveness and safety of 'Sandwich treatment' strategy for large brain metastases (LBM) with diameter over 3 cm (minimum volume >= 15 cm3) located in motor area. PATIENTS AND METHODS: Patients from four gamma knife center that received 'Sandwich treatment' were retrospectively studied from January 2016 to March 2023. The strategy was one-week treatment course including 2 stages of stereotactic radiosurgery (SRS) and using bevacizumab once during SRS gap. The tumor volume and peri-tumor edema changes were analyzed before and after 'Sandwich treatment'. Manual muscle testing (MMT) score and Barthel Index (BI) score were used to evaluate the changes of patients' movement and physical strength rehabilitation. The patients' overall survival (OS) and tumor local control (TLC) rate was calculated. Cox regression model was used to analyze the risk factors that related to TLC. RESULTS: 61 patients with 72 lesions received the 'Sandwich treatment'. The median prescription dose was 13.0 Gy and 12.5 Gy at the first- and second-stage SRS. The mean tumor volume at the time of 'Sandwich treatment' and 3 months later was 20.1 cm3 and 12.3, respectively (P < 0.01). The mean peri-tumor edema volume at the first- and second-stage SRS was 12.6 cm3 and 5.2 cm3, respectively (P < 0.01). Patients' median MMT score improved from 6 at the beginning to 8 at the end of 'Sandwich treatment' (P < 0.01), BI score was also greatly improved from 45 at the time of 'Sandwich treatment' to 95 after 3 months (P < 0.01). Patients' median OS was 14.0 months, and the 3, 6, 12 months OS rate was 92.0%, 86.0% and 66.0%, respectively. The TLC rate at 3, 6, 12 months was 98.4%, 93.4%, and 85.3%, respectively. Patients with lung cancer had lower risk of tumor relapse. The cumulative incidence of patient's hemorrhage and radiation necrosis was 4.92% (3/61) and 13.11% (8/61) after 'Sandwich treatment'. CONCLUSIONS: 'Sandwich treatment' strategy is safe and effective for LBM located in motor area. The strategy could rapidly improve the patients' movement and enhance their physical strength rehabilitation.

Efficacy and safety of a "sandwich therapy" based on staged stereotactic radiosurgery and bevacizumab for large brainstem metastases.

OBJECTIVE: Gamma Knife stereotactic radiosurgery (SRS) is an effective therapeutic option for unresectable brainstem metastases. Currently, staged stereotactic radiosurgery (SSRS) has become available for large brainstem metastases（≥ 1 cm3） despite the limitation of peritumoral edema. The authors developed the so-called "sandwich therapy" which integrated 2-stage stereotactic radiosurgery (2-SSRS) with bevacizumab for peritumoral edema reduction and local control of large brainstem metastases. METHODS: 42 patients with large brainstem metastases ≥1 cm3 who received 2-SSRS simultaneously with bevacizumab were screened from 2019 to 2021 retrospectively. The first SRS margin doses were 13 Gy (range 11-15) and the second SRS margin doses were 12 Gy (range 11-13), one-time vascular endothelial growth factor (VEGF) inhibitor (bevacizumab) of 3.5-5 mg/kg was administrated intravenously the next day after the first SRS. The median interval between the two sessions of SRS was 6 days. Baseline demographics, clinical and radiology imaging follow-ups were recorded to determine symptomatic improvement, peritumoral edema reduction, local control, and disease progression. Median survival was calculated using Kaplan-Meier analysis. Multivariate analysis was performed to identify prognostic factors. RESULTS: The "sandwich therapy" was applied to 42 lesions. Significant reductions of tumor volume (p < 0.05) and peritumoral edema volume (p < 0.01) were achieved at the second SRS in comparison to those at the first SRS. The proportion of favorable Karnofsky performance scale (KPS) (≥80 %) increased significantly at early follow-up time points and reached the highest value of 85.7 %. The median survival time was 9.7 months, the median local control duration was 11.3 months. 8 acute adverse events of CTCAE grade 2 and 3 were observed in 6 patients and resolved with palliative treatment. Tyrosine kinase inhibitor (TKI) treatment was identified as a predictive factor for longer survival. CONCLUSION: The "sandwich therapy" which integrates 2-SSRS with bevacizumab is a safe and effective option for large brainstem metastases.

'Sandwich treatment' for posterior fossa brain metastases with volume larger than 4cm3: a multicentric retrospective study.

Single stereotactic radiosurgery (SRS) for posterior fossa brain metastases (BM) larger than 4cm3 is dangerous. 'Sandwich treatment' strategy was developed for these BMs. The strategy was one week treatment course which includes 2-stage SRS and using Bevacizumab once during SRS gap. Patients from four gamma knife center were retrospectively analyzed. The changes of tumor and peri-tumor edema volume were studied. The Dizziness Handicap Inventory (DHI) Vomiting Score (VS) and Glasgow Coma Scale (GCS) were used to evaluate patients' clinical symptom changes. Karnofsky performance scale (KPS) and Barthel Index (BI) were used to evaluate patients' overall fitness status and physical activity rehabilitation. Tumor local control (TLC) and patients' overall survival (OS) rate were also calculated. Forty patients with 45 LBMs received 'Sandwich treatment'. The mean edema volume reduced remarkably at the course of therapy and 3 months later (P < 0.01). The mean tumor volume greatly decreased 3 months later (P < 0.01). Patients' clinical symptoms that reflected by median score of DHI, VS, GCS were improved dramatically at the course of therapy and 3 months later (P < 0.01). Similar changes happened in median score of KPS and BI that reflected patients' overall fitness status and physical activity rehabilitation (P < 0.01). Patients' median OS was 14.3 months, with 95.4%, 76.2%, and 26.3% survival rate at 6, 12, 24 months. The TLC rate at 6, 12, 24 months was 97.5%, 86.0% and 62.2%.The 'Sandwich treatment' is safe and effective for patients with LBM over 4cm3 in the posterior fossa. The strategy could quickly improve patients' symptoms, well control tumor growth, prolong patient's OS, and has controllable side effects.

Influence of plasticizer level on the drug release from sustained release film coated and hot-melt extruded dosage forms.

In the current study, the influence of plasticizer level on drug release was investigated for solid dosage forms prepared by hot-melt extrusion and film coating. The properties of two highly water-soluble compounds, diltiazem hydrochloride (DTZ) and chlorpheniramine maleate (CPM), and a poorly water-soluble drug, indomethacin (IDM), were investigated in the melt extrudates containing either Eudragit RSPO or Eudragit RD 100 and triethyl citrate (TEC) as the plasticizer. In addition, pellets containing DTZ were film coated with Eudragit RS 30D and varying levels of TEC using a fluidized bed coating unit. Differential scanning calorimetry (DSC) demonstrated that both CPM and IDM exhibited a plasticization effect on the acrylic polymers, whereas no plasticizing effect by DTZ on Eudragit RSPO was observed. Thermogravimetric analysis (TGA) was used to investigate the thermal stability of the DTZ, Eudragit RSPO and TEC at 140 degrees C, the maximum temperature used in the hot-melt extrusion process. The chemical stability of DTZ and IDM in the extrudate following hot-melt processing was determined by high pressure liquid chromatography (HPLC). Drug release rates of both DTZ and CPM from hot-melt extrudates increased with an increase in the TEC level in the formulations, while the release rate of DTZ from the Eudragit RS 30D-coated pellets decreased with an increase in TEC in the coating dispersion. This phenomenon was due to the formation of a reservoir polymeric structure as a result of the thermal stress and shear stress involved in the hot-melt extrusion process regardless of the TEC level. In contrast, coalescence of the polymer particles in the film coating process was enhanced with higher levels of TEC, as demonstrated by scanning electron microscopy (SEM). The addition of TEC (0% to 8%) in the IDM hot-melt extrudate formulation had no influence on the drug release rate as the drug release rate was controlled by drug diffusion through the inside of the polymeric materials rather than between the polymer particles.

Controlled release of a poorly water-soluble drug from hot-melt extrudates containing acrylic polymers.

Controlled release tablets containing a poorly water-soluble drug, indomethacin (IDM), acrylic polymers (Eudragit RD 100, Eudragit L 100, or Eudragit S 100), and triethyl citrate (TEC) were prepared by hot-melt extrusion. The physicochemical and IDM release properties of the controlled release hot-melt extrudates were investigated. Indomethacin (IDM) was found to be both thermally and chemically stable following hot-melt extrusion processing and displayed a plasticizing effect on Eudragit RL PO as demonstrated by a decrease in the glass transition temperatures of the polymer. The inclusion of either Pluronic F68, Eudragit L 100, or Eudragit S 100 in the powder blend containing Eudragit RD 100 prior to processing increased the rate of release of the IDM from the extrudates. An increase in the media pH and a decrease in the granule particle size also increased the rate of release of IDM. The inclusion of TEC up to 8% in the granule formulation or compressing the granules into tablets had no significant effect on the drug release rate. Indomethacin (IDM) was transformed from a crystalline Form I into an amorphous form in the Eudragit RD 100 granules following hot-melt extrusion. The thermal processing facilitated the formation of a solid solution with a continuous matrix structure that was shown to control drug diffusion from the extrudates.

Influence of thermal processing on the properties of chlorpheniramine maleate tablets containing an acrylic polymer.

The purpose of this investigation was to determine the effects of thermal processing and post-processing thermal treatment on the release properties of chlorpheniramine maleate (CPM) from matrix tablets containing Eudragit RS PO and triethyl citrate (TEC). CPM tablets containing Eudragit RS PO with and without TEC were prepared by direct compression (DC), high shear hot-melt granulation (HMG), and hot-melt extrusion (HME). X-ray diffraction patterns showed that the CPM was distributed in Eudragit RS PO at the molecular level following HME. The thermogravimetry analysis (TGA) profiles of CPM, Eudragit RS PO, and TEC demonstrated that these materials were thermally stable during both the high shear HMG and HME processes. The tablets were subjected to post-processing thermal treatment by storing the tablets at 60 degrees C in open containers for 24 hr. Tablets prepared by DC showed the highest drug release rate constant of 36.2% hr-1/2. When 4% TEC was incorporated into the formulation, the drug release rate constant for the directly compressed tablets decreased to 32.4% hr-1/2. After high shear HMG and HME of the powder blend containing 4% TEC, the drug release rate constant decreased to 30.8 and 13.8% hr-1/2 for the respective processes. The drug release rate constants for all tablets decreased following post-processing thermal treatment. The reduction in release rate was due to an increase in the intermolecular binding and entanglement between drug molecules and polymer molecules that occurred during thermal processing. Post-processing thermal treatment of the hot-melt extrudates had a minimal effect on the drug release rate since the HME process enhanced the drug and polymer entanglement to a greater extent.

Solid-state plasticization of an acrylic polymer with chlorpheniramine maleate and triethyl citrate.

The influence of in situ plasticization of chlorpheniramine maleate (CPM) on Eudragit RS PO from hot-melt extruded matrix tablets, and from compressed granules prepared by thermal processing was investigated. CPM was studied as both a model drug substance and as a solid-state plasticizer for the acrylic polymer. Triethyl citrate (TEC) was incorporated into the polymer blend as a liquid plasticizer for the polymer. The influence of TEC and CPM concentration on the dissolution properties of CPM tablets was investigated. The glass transition temperature (T(g)) of the samples was determined by modulated differential scanning calorimetry (MDSC). The morphologies of the granules formed by hot-melt extrusion and hot-melt granulation processes were investigated by scanning electron microscopy. The addition of 12% TEC to the polymer reduced the T(g) by 32.5 degrees C, while the reduction in the T(g) for the same level of CPM was 16.4 degrees C. The effect of TEC levels on drug release was dependent on the tablet preparation method. At high TEC levels, the release rate of CPM decreased in tablets prepared by direct compression and tablets made from compressed granules that had been prepared by high shear hot-melt granulation. However, the CPM release rate increased from hot-melt extruded tablets with increasing blends of plasticizer in the extruded tablets. An increase in the CPM content in the tablets resulted in an increase in the drug release rate. During high shear hot-melt granulation, the model drug adhered to the polymer to form a porous discontinuous structure. Following hot-melt extrusion, the drug was distributed at a molecular level in the continuous polymeric structure. The influence of both CPM and TEC levels on the drug release rate from these polymeric drug delivery systems was shown to be a function of whether the granules or tablets were formed by either hot-melt granulation or hot-melt extrusion, as well as the plasticization effects of both TEC and CPM on the acrylic polymer.