Liver resection versus transarterial chemoembolization for huge hepatocellular carcinoma: a propensity score matched analysis.

To date, it is unclear which treatment modality, liver resection (LR) or transarterial chemoembolization (TACE) is the more appropriate for patients with huge (≥ 10 cm) hepatocellular carcinoma (HCC). The study aim was to compare, using propensity score matching, short- and long-term outcomes of patients with huge HCC who underwent potentially curative LR or TACE. Patients with huge HCC who had been managed at the Clinical Center by curative-intent LR or by palliative TACE between November 2001 and December 2018 were retrospectively identified. The morbidity and mortality rates and overall survival were compared between the groups before and after the propensity score matching. Independent predictors of long-term survival were determined by multivariate analysis. A total of 103 patients with huge HCC were included; 68 were assigned to the LR group and 35 to the TACE group. The overall morbidity rate was higher in the LR group than in the TACE group before matching (64.7% vs. 37.1%, p = 0.012), while there was no difference after matching (60% vs. 30%, p = 0.055). The major morbidity and 30-days mortality were similar between the groups before and after matching. The LR group was associated with longer overall survival than the TACE group before matching (p = 0.032) and after matching (p = 0.023). Total bilirubin and TACE treatment were independent prognostic factors associated with long-term survival. In patients with huge HCC, liver resection provides better long-term survival than TACE and should be considered as the initial treatment whenever possible.

Standardized perfusion value of the esophageal carcinoma and its correlation with quantitative CT perfusion parameter values.

PURPOSE: Standardized perfusion value (SPV) is a universal indicator of tissue perfusion, normalized to the whole-body perfusion, which was proposed to simplify, unify and allow the interchangeability among the perfusion measurements and comparison between the tumor perfusion and metabolism. The aims of our study were to assess the standardized perfusion value (SPV) of the esophageal carcinoma, and its correlation with quantitative CT perfusion measurements: blood flow (BF), blood volume (BV), mean transit time (MTT) and permeability surface area product (PS) of the same tumor volume samples, which were obtained by deconvolution-based CT perfusion analysis. METHODS: Forty CT perfusion studies of the esophageal cancer were analyzed, using the commercial deconvolution-based CT perfusion software (Perfusion 3.0, GE Healthcare). The SPV of the esophageal tumor and neighboring skeletal muscle were correlated with the corresponding mean tumor and muscle quantitative CT perfusion parameter values, using Spearman's rank correlation coefficient (rS). RESULTS: Median SPV of the esophageal carcinoma (7.1; range: 2.8-13.4) significantly differed from the SPV of the skeletal muscle (median: 1.0; range: 0.4-2.4), (Z=-5.511, p<0.001). The cut-off value of the SPV of 2.5 enabled discrimination of esophageal cancer from the skeletal muscle with sensitivity and specificity of 100%. SPV of the esophageal carcinoma significantly correlated with corresponding tumor BF (rS=0.484, p=0.002), BV (rS=0.637, p<0.001) and PS (rS=0.432, p=0.005), and SPV of the skeletal muscle significantly correlated with corresponding muscle BF (rS=0.573, p<0.001), BV (rS=0.849, p<0.001) and PS (rS=0.761, p<0.001). CONCLUSIONS: We presented a database of the SPV for the esophageal cancer and proved that SPV of the esophageal neoplasm significantly differs from the SPV of the skeletal muscle, which represented a sample of healthy tissue. The SPV was validated against quantitative CT perfusion measurements and statistically significant correlation was proved.

Comparison between the deconvolution and maximum slope 64-MDCT perfusion analysis of the esophageal cancer: is conversion possible?

PURPOSE: To estimate if CT perfusion parameter values of the esophageal cancer, which were obtained with the deconvolution-based software and maximum slope algorithm are in agreement, or at least interchangeable. METHODS: 278 esophageal tumor ROIs, derived from 35 CT perfusion studies that were performed with a 64-MDCT, were analyzed. "Slice-by-slice" and average "whole-covered-tumor-volume" analysis was performed. Tumor blood flow and blood volume were manually calculated from the arterial tumor-time-density graphs, according to the maximum slope methodology (BF(ms) and BV(ms)), and compared with the corresponding perfusion values, which were automatically computed by commercial deconvolution-based software (BF(deconvolution) and BV(deconvolution)), for the same tumor ROIs. Statistical analysis was performed using Wilcoxon matched-pairs test, paired-samples t-test, Spearman and Pearson correlation coefficients, and Bland-Altman agreement plots. RESULTS: BF(deconvolution) (median: 74.75 ml/min/100g, range, 18.00-230.5) significantly exceeded the BF(ms) (25.39 ml/min/100g, range, 7.13-96.41) (Z=-14.390, p<0.001), while BV(deconvolution) (median: 5.70 ml/100g, range: 2.10-15.90) descended the BV(ms) (9.37 ml/100g, range: 3.44-19.40) (Z=-13.868, p<0.001). Both pairs of perfusion measurements significantly correlated with each other: BF(deconvolution), versus BF(ms) (rS=0.585, p<0.001), and BV(deconvolution), versus BV(ms) (rS=0.602, p<0.001). Geometric mean BF(deconvolution)/BF(ms) ratio was 2.8 (range, 1.1-6.8), while geometric mean BV(deconvolution)/BV(ms) ratio was 0.6 (range, 0.3-1.1), within 95% limits of agreement. CONCLUSIONS: Significantly different CT perfusion values of the esophageal cancer blood flow and blood volume were obtained by deconvolution-based and maximum slope-based algorithms, although they correlated significantly with each other. Two perfusion-measuring algorithms are not interchangeable because too wide ranges of the conversion factors were found.

Percutaneous nephrostomy in the management of advanced and terminal-stage gynecologic malignancies: outcome and complications.

PURPOSE: The goal of the study was to evaluate the outcome and complications after percutaneous nephrostomy (PCN) insertion in advanced and terminal-stage gynecological malignancies with ureteral obstruction (UO). MATERIALS AND METHODS: We analyzed data of 117 patients with UO due to gynecological malignancies, who had undergone PCN between 1996 and 2006. Cervical cancer was evidenced in 108 patients, uterine carcinoma in six and ovarian cancer in three patients. Eighty-nine had UO at the initial manifestation of the disease, 22 had persistent or recurrent cancer, and six were disease-free after initial therapy. Oliguria was observed in 22.2% and creatine elevation in 79.5%. Mean follow-up was 11.43 months (range 0-112). RESULTS: The median age was 51 years (range 28-85). Bilateral nephrostomy was performed in 36.7% and unilateral in 63.3%. Renal function normalization occurred in 24.8%. Overall two-year survival (OS) was 16.8%. Higher OS occurred in patients without initial azotemia versus those with azotemia (26.8% vs 13.9%). Median survival time for all the patients was seven months, eight in primary cases versus six in recurrent ones, and eight months in patients after initial therapy. Complications appeared in 53.85%. Most frequent were the loss of the nephrostomy catheter in 37.61% and urinary tract infections in 19.6%. CONCLUSION: Improvement of renal function after PCN can be of clinical benefit in patients who might be cured or for prolonged palliative care. Azotemia seems to be poor prognostic sign.

[Delayed MDCT in preoperative analysis of the hypopharyngeal postcricoid carcinomas].

INTRODUCTION: Determination of borders of the postcricoid tumors is of great significance during preoperative analysis, because it can be of considerable influence on operative treatment and its planning. Therefore, exact demarcation, delineation and opacification of tumor zone on CT analysis is crucial. MATERIAL AND METHOD: Late CT scan delay of 150 sec and slow vein flow of contrast agents of 1 ml/sec is radiological method of choice in preoperative evaluation of carcinoma of the post-cricoid region. For our purposes we used modern MSCT Light Speed GE 64, with slice thick of 2.5 mm (retro recon of 0.625) with software postprocesing. RESULTS AND DISCUSSION: In our study, we have detaily analized 25 patients with clinically proved carcinoma of hypopharynx, of which 8 had the hardest form of tumor. Control group were patients to whom CT scan was done by standard protocol and CT time scan of 50 sec. With all 8 of them, scanned by protocol of delay time of 150 sec, was proved a statistically important validity of interpretation and demarcation of tumors. CONCLUSION: Delay time on CT scanning is proved to be efficient protocol for visualization of neck soft tissues which includes the walls of hypopharynx.

[Clinico-radiological characteristics of bronchial carcinoid].

OBJECTIVES: To review clinical and radiological characteristics of a patients with bronchial carcinoid. METHODS: In this retrospective study, we reviewed the clinical, pathological and imaging findings in 42 patients diagnosed with bronchial carcinoid during the seven years period. RESULTS: There were 23 women and 19 men, with a mean age of 47 years (range from 15 to 75). Thirty patients had typical and 12 atypical bronchial carcinoid. Dominant symtoms were cough (46.7%) and 38%. Tumor was localized in 28 patients in the left, and 14 in the right lung. On radiographs carcinoid manifested as tumor shadow in 40.5%, nodule and atelectasis in 21.4% cases each respectively, pleural effusion and pneumonia in 7.1% each respectively and hyperinflation in 2.4% of the cases. Computerized tomography revealed endoluminal tumor in 30.9% patients. CONCLUSION: Major imaging findings are central, tumor mass or nodule and obstruction signs like atelectasis. Diagnosis is confirmed by pathological examination of samples taken by bronchoscopy or surgery.

[Radiologic manifestation of primary pleural tumors].

OBJECTIVES: To show the radiological manifestations of primary pleural tumors. PATIENTS AND METHODS: we carried out a retrospective analysis of radiological findings in 62 patients with primary malignant tumor of pleura. RESULTS: Study included 39 male and 23 female patients. Malignant tumors were present in 92.7% of the patients and benign ones in 7.2%. The most common malignant tumor was mesothelioma (85.4%), and solitary fibrous tumor prevailed among benign tumors (9.7%). Diffuse malignant mesothelioma manifested on computed tomography (CT) as a pleural thickening and effusion in 67.4% of the patients, tumors and effusion in 11.7%, and only as an effusion in 9.8% cases. Thickening of the pleura appeared diffuse in 54% of patients and most often it had nodular pattern. Both localized malignant and all benign tumors presented as tumor-like changes with the signs of necrosis in 50%. CONCLUSION: The imaging methods have a key role in the diagnosis of pleural tumors. CT shows different morphologic features of pleural lesions that have been established as a useful tool for differentiating malignant from benign disease. However, magnetic resonance is preferred imaging method for assessing the extent and resectability of pleural tumors.

[Solving of complications arising during and after application self-expandible metallic stents in palliation of malignant dysphagia].

INTRODUCTION: During palliative treatment of malignant disphagia in inoperabile patients various and serious complications may occur and compromite the method of treatment if there were not solved. AIM: Goal is to present the most frequent complications due to esophageal stenting and the way of their solving. MATERIALS AND METHOD: From 1996. to 2009. in 237 patients (164 esophageal carcinoma, 33 carcinoma of the esophagogastric junction, 14 bronchial carcinoma, 7 esophagojejunal anastomosis, 9 esophageal fistulas) 245 stents have been placed (54 uncovered and 191 covered). Mean survival period was 14.7 months (ranged from 1 do 33 months). Esophageal perforation (1), stent migration (9), malignant tissue ingrowth (31) and overgrowth (24) have been revealed by barium contrast study during follow up. Perforation was solved by placing covered stent, migration by removing migrated stent endoscopically or surgically, ingrowth and overgrowth by balon dilating or restenting under the fluoroscopically guidance and control. CONCLUSION: One can expect and recognize complications regarding esophageal stenting because it is the only way for their sucsessfull treatment.

[X-ray and CT presentation of advanced gastric carcinomas of different locations].

We presented the X-ray and CT findings characteristic for gastric cancers of different localizations (localized in different parts of the stomach). Particularly, esophagogastric junction (EGJ) carcinomas and antral carcinomas are singled out, as two localizations of gastric cancer that we usually meet in everyday clinical and radiological practice, and which have completely different radiological presentation. Advanced carcinomas of esophago-gastric junction, whose incidence is on the rise, usually affect the distal segment of the esophagus, cardia, and proximal part of the stomach, in different proportions. Siewert's, and the Japanese classification of these tumors are listed. Due to the involvement of the distal esophagus, scanning region, besides the abdomen, should be expanded to the chest. Advanced cancer of the antral part of the stomach is presented by the X-ray as a fungating, infiltrative, or combined form, often capturing the entire wall circumference. Possible infiltration of the left liver, the body and neck of the pancreas, colon and anterior abdominal wall should be estimated by CT.

[Computerized tomography in postoperative monitoring of patients with the Whipple operation--characteristics of CT findings].

We presented the postoperative CT findings of patients after the Whipple's operation (cephalic pancreaticoduodenectomy), performed for the pancreatic head cancer, or ampullary carcinoma. Technique of the Whipple's operation is described, and normal and pathological postoperative CT findings, which are characteristic for the immediate (early) and delayed (late) follow-up period, are presented. In addition, difficulties in differentiation of afferent jejunal loop from the recurrent tumor by CT are discussed, and references from the literature about the possibilities of successful visualization of the afferent jejunal loop are cited. Possible locations and CT appearances of the tumor recurrences are presented. An overview of the literature is provided.

[Diagnostic value of diffusion weighted imaging in assessment of malignant focal liver lesions].

INTRODUCTION: The study was designed to determine if there was a difference between apparent diffusion coefficient (ADC) values using diffusion weighted imaging (DWI) MRI technique between different malignant focal liver lesions. PATIENTS AND METHODS: The study included 63 patients with focal hepatic lesions: fourteen patients (22.2%) with hepatocellular carcinoma (HCC), 16 patients (25.4%) with hepatic metastatic colorectal tumors, 17 patients (26.9%) with cavernous haemangioma and 16 patients (25.4%) with hepatic cysts. MRI was performed with 1.5T scanner, using EPI sequence with ADC values being determined for all lesions based on three b values. RESULTS: ADC values were statistically different among the groups (F = 70.7, p < 0.01): HCC patients 1.11 +/- 0.29 x 10(-3) s/mm2, metastatic tumours 2.18 +/- 0.15 x 10(-3) s/mm2, haemangioma 2.22 +/- 0.32 x 10(-3) s/mm, cysts 3.08 +/- 0.03 x 10(-3) s/mm2. Furthermore, there was statistically significant difference between benign lesions (haemangiom and cysts, 2.36 +/- 0.43 x 10(-3) s/mm2), and malignant diseases (HCC and secondary tumors, 1.52 +/- 0.58 x 10(-3) s/mm2), t = 5,6, p < 0.01. CONCLUSION: DWI technique could be helpful in defining the focal liver lesions.

[Magnetic resonance cholangiopancreatography: diagnostic significance in malignant diseases of bile and pancreatic ducts].

Magnetic resonance cholangiopancreatography (MR CP) is a relatively new, noninvasive method in patients with pancreaticobiliary diseases, which is comparable to invasive endoscopic retrograde cholangiopancreatography (ERCP). One of the most common indications for MRCP is malignant obstruction of the bile and pancreatic ducts. Standard imaging protocol includes routine abdominal study followed by a sequence for MRCP adapted to each of the patients and site of the malignant process. MRCP is a simple to perform, does not exposure the patients to radiation, requires no anesthesia, is less operator dependent and allows better visualization of ducts proximal to an obstruction. Thus, during one examination only, it is possible to assess not only pancreaticobiliary system but also abdominal structures, which increases diagnostic value of MR and is therefore, optimal method in evaluation of these patients.

[The future of transcatheter antitumor therapy].

Transcatheter antitumor therapy very quickly accepted during the last decade and their importance in the treatment of oncology patients will be increasing. By improvement of new targeted agents, which can be given intraarterial or systemic, efficiency of transcatheteric therapeutic approaches can be drastically increased. Numerous clinical trials (study phase I / II / III) relating to the synergy of two antitumor therapeutic approaches are already in progress. Preliminary results of these trials are already very encouraging. Further improvement in the development of specific therapeutics antitumor drugs and systemic applications will be a big step in the quest for medication against malignant tumors.

[Transcatether chemoembolization in the treatment of hepatocellular carcinoma].

UNLABELLED: The authors describe their own experience with chemoembolization as a palliation in the treatment of non resectable hepatocellular carcinoma. MATERIAL/METHODS: During period of 64 months procedure was performed in 41 patients with non resectable hepatocellular carcinoma. The combination of Lipiodol and chemotherapeutic agents were applied in a. hepatica propria and its branches via transfemorally placed catheter. Stages of neoplasms were defined by Okuda method. RESULTS: The majority of tumors (30) were classified as Grade I. Liver cirrhosis was present in 36 patients, and abnormal levels of alpha-fetoprotein were found in 68% of cases. Each of twenty nine patients had more than one chemoembolization therapy, therefore, a total of 85 treatments were carried out. CT scanning perfomed one month following the procedure revealed more than 75% of Lipiodol retention in 42% of cases, and over 90% of neoplasm necrosis was recorded in 90% of cases, while all treated patients manifested lower levels of alpha-fetoprotein. All patients survived during three and six months, respectively, while the survival rate was 68% after 18 months. No letal outcome was reported during procedure, and morbidity in relation to total number of interventions was 19%. CONCLUSION: Achieved effects of this relatively safe procedure in our series do not differ significantly from those in the literature.

[Extracorporeal percutaneous biliary-gastric "bypass" in patients with irreversible cholestasis of malignant etiology].

Authors present rarely and unusual original methods for billiary drainage type as combination of exsternal drainage and percutaneus gastrostomy. Method used in four patients with irreversibile obstruction during the last 3 years in Inteventional Radiology Dept. Clinical Center of Serbia. In all cases we have satisfactory results with survival time of about 30 days.

[How to prevent tissue overgrowth and incrustation of metal stents in the urinary tract in patients with pelvic malignancy] b ].

At the current level of stent application in urology each irreversible urostasis contraindicated for surgical therapy implies consideration of indications for metal stent insertion. Stent incrustation which leads directly into a new uroobstruction is a characteristic complication of this method. Available experience in different uroobstructive conditions has shown that very different clinical aspects of stent usage may directly determine the possibility of their incrustation. Stent incrustation may occur in the early postprocedural course or several months later. After that, prevention of stent incrustation starts with postprocedural evaluation, selection of the stent type, and it is subsequently continued by insertion technique and lasts practically permanently after the insertion (infection control, promotion of diuresis and maintenance of normal urodynamics). Authors present own experianse in clinical aplication of metal stents in uroradiology strictures for period of last 15 years.

The accuracy of ultrasonography in classification of groin hernias according to the criteria of the unified classification system.

BACKGROUND: The modern concept of type-related individualized groin hernia surgery imposes a demand for precise and accurate preoperative determination of the type of groin hernia. The aim of this prospective study was to evaluate the accuracy of ultrasonography in classification of groin hernias, according to the criteria of the unified classification system. Unified classification divides groin hernias into nine types (grades): type I (indirect, small), II (indirect, medium), III (indirect, large), IV (direct, small), V (direct, medium), VI (direct, large), VII (combined-pantaloon), VIII (femoral), and O (other). PATIENTS AND METHODS: One hundred and twenty-five adult patients with clinically diagnosed or suspected groin hernias were examined. Ultrasonography of both groins was performed with a 5 to 10-MHz linear-array transducer. Preoperative ultrasonographic findings of type of groin hernia were compared with the intraoperative findings, which were considered the gold standard. RESULTS: Total accuracy of ultrasonography in determination of type of groin hernia was 96% (119 of 124 correct predictions of type of groin hernia compared with surgical explorations). All hernias of types I, IV, V, VII, and VIII were correctly identified with ultrasonography (sensitivity and specificity 100%). In the remaining five cases of the 124 (4%), hernia was incorrectly classified with ultrasonography: type VI (direct, large) was misdiagnosed as type III (indirect, large) in three cases, type III as type VI in one case, and type III as type II (indirect, medium) in one case. The sensitivity and the specificity of ultrasonography in classifying type II were 100 and 99%, respectively, for type III, 85 and 97%, and for type VI, 90 and 99%. CONCLUSION: Ultrasonography of the groin regions could be used with great accuracy for precise classification of groin hernias in adults. Each type of groin hernia, according to the unified classification system that we used for classification, has a characteristic ultrasonographic presentation, which is demonstrated in this study.