A Case of Severe Rectal Hemorrhage Possibly Caused by Radiation Recall after Administration of Gemcitabine.

Radiation recall is an acute inflammatory reaction that can be triggered when systemic agents are administered long time after radiotherapy. Because radiotherapy is now indicated for many types of cancer, care should be taken regarding possible toxic events relating to radiotherapy in combination with radio-sensitizing agents. Gemcitabine, one such anti-cancer agent, is widely used, especially for urologic cancers. We report an intriguing case of possible radiation recall in the rectum caused by gemcitabine administration 37 years after radiation therapy. From a review of the literature, it appears that there have been no reported cases of radiation recall in the rectum with such a long interval between radiation therapy and chemotherapy. Here, we describe the case and provide a literature review.

Evaluation of safety and efficacy of transjugular liver biopsy in allogeneic hematopoietic stem cell transplant recipients.

We retrospectively evaluated the safety and utility of transjugular liver biopsy (TJLB) in allogeneic hematopoietic stem cell transplant (HSCT) recipients. Ten patients underwent HSCT between 1991 and 2013. Eight patients with thrombocytopenia received platelet transfusions before and/or during TJLB. No complications associated with TJLB were observed. Samples adequate for a pathological diagnosis were obtained in 9 of the 10 patients, and the diagnoses made by TJLB were graft-versus-host-disease in eight patients and non-specific hepatitis in one. These results suggest that TJLB is a safe and effective procedure for the evaluation of liver injury in HSCT recipients.

Visualization of the right adrenal vein using CT during right inferior phrenic arteriography in hepatocellular carcinoma patients.

OBJECTIVE: The objective of this retrospective study was to determine the frequency of right adrenal vein identification by computed tomography (CT) during right inferior phrenic arteriography (CTRIPA) and to describe the spectrum of anatomic variations of the right adrenal vein. MATERIALS AND METHODS: CTRIPA performed on 104 patients treated with transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma in our hospital between August 2007 and July 2013 were reviewed. The right adrenal vein on CTRIPA images was evaluated for degree of visualization, anatomic variation, anatomic features, vessel direction, and length. CTRIPA images were compared with dynamic CT before TACE. RESULTS: Partial or entire enhancement of the adrenal gland was obtained in 101 patients. The right adrenal vein was detected using CTRIPA in 97% (98/101) of patients, which was significantly higher than detection using dynamic multidetector CT (MDCT) [77% (78/101)]. Vessel length and diameter averaged 8.5 ± 3.8 and 1.6 ± 0.5 mm, respectively. CTRIPA also showed venous drainage into the right capsular renal vein in nine patients. CONCLUSION: Almost all right adrenal veins were visualized using CTRIPA; the detection rate was significantly higher on CTRIPA than on MDCT before TACE.

Large renal arteriovenous fistula with left-sided inferior vena cava.

Idiopathic renal arteriovenous fistulas (RAVFs) are uncommon, and a left-sided inferior vena cava (IVC) is also rare. We report a large idiopathic RAVF in a 36-year-old woman who had progressive congestive heart failure. An abdominal computed tomographic scan revealed an enlarged IVC on the left side and a 5.0-×4.5-cm RAVF with a single communication between the left renal artery and vein. Transcatheter embolization was not performed because complete flow control by a balloon catheter could not be achieved. Because of the size of the RAVF and the left-sided position of the IVC, nephrectomy was performed.

Short-term therapeutic effects of transcatheter arterial chemoembolization using miriplatin-lipiodol suspension for hepatocellular carcinoma.

PURPOSE: To retrospectively investigate the short-term therapeutic effects and adverse effects associated with the use of miriplatin-lipiodol suspension for transcatheter arterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC), using TACE with cisplatin-lipiodol suspension as the historical control. MATERIALS AND METHODS: The study was conducted on 48 and 50 consecutive patients with HCC who underwent TACE with miriplatin-lipiodol suspension and cisplatin-lipiodol suspension, respectively. Therapeutic effect was evaluated by mRECIST. Adverse effects were graded by CTCAE, version 4.0. The therapeutic and adverse effects were compared using Fisher's exact test and multivariate logistic regression. RESULTS: Complete remission, partial response, stable disease and progressive disease were observed in 37.5, 18.8, 33.3 and 10.4 % of patients in the miriplatin group, with the corresponding percentages being 54.0, 32.0, 14.0 and 0.0 %, respectively, in the cisplatin group. The short-term therapeutic effects were statistically significantly worse in the miriplatin group than in the cisplatin group, even after adjustment for tumor size and Child-Pugh class. The rates of nausea and serum creatinine elevation were statistically significantly lower in the miriplatin group (p < 0.05). CONCLUSION: TACE using miriplatin-lipiodol suspension yielded worse short-term responses than cisplatin-lipiodol suspension; however, the rates of adverse events were significantly lower in the miriplatin group.

Hemobilia due to biliary intraepithelial neoplasia associated with Zollinger-Ellison syndrome.

A 58-year-old man was transferred to us from his local hospital because of failure to control his gastrointestinal bleeding by endoscopic hemostasis. Abdominal imaging suggested a hypervascular tumor of the pancreatic head (36 mm diameter), and laboratory testing showed an elevated serum gastrin level (17,800 pg/mL). Gastroduodenal endoscopy revealed multiple duodenal ulcers and active bleeding from the ampulla of Vater. The selective arterial secretagogue injection test suggested a gastrinoma in the pancreatic head, but no gastrinoma in the pancreatic tail. The patient was diagnosed with solitary pancreatic head gastrinoma complicated by hemosuccus pancreaticus, and pancreaticoduodenectomy was performed. Intraoperatively, the diagnosis was changed to primary peripancreatic lymph node gastrinoma without pancreatic involvement. The gastrointestinal bleeding stopped postoperatively and serum gastrin levels returned to normal. Histological examination of the surgical specimens revealed a small submucosal gastrinoma in the duodenum (7 mm diameter). The final diagnosis was microgastrinoma of the duodenum with peripancreatic lymph node metastasis. The cause of bleeding from the ampulla of Vater was initially obscure, but eventually a hemorrhagic erosion with moderate atypia was found in the common bile duct, indicating biliary intraepithelial neoplasia (BilIN). This is the first report of hemobilia due to BilIN with gastrinoma.

Radiosurgical treatment planning for intracranial AVM based on images generated by principal component analysis--a simulation study.

BACKGROUND: One of the most important factors in stereotactic radiosurgery (SRS) for intracranial arteriovenous malformation (AVM) is to determine accurate target delineation of the nidus. However, since intracranial AVMs are complicated in structure, it is often difficult to clearly determine the target delineation. PURPOSE: To investigate the usefulness of principal component analysis (PCA) on intra-arterial contrast enhanced dynamic CT (IADCT) images as a tool for delineating accurate target volumes for stereotactic radiosurgery of AVMs. MATERIALS AND METHODS: IADCT and intravenous contrast-enhanced CT (IVCT) were used to examine 4 randomly selected cases of AVM. PCA images were generated from the IADCT data. The first component images were considered feeding artery predominant, the second component images were considered draining vein predominant, and the third component images were considered background. Target delineations were first carried out from IVCT, and then again while referring to the first and second components of the PCA images. Dose calculation simulations for radiosurgical treatment plans with IVCT and PCA images were performed. Dose volume histograms of the vein areas as well as the target volumes were compared. RESULTS: In all cases, the calculated target volumes based on IVCT images were larger than those based on PCA images, and the irradiation doses for the vein areas were reduced. CONCLUSION: In this study, we simulated radiosurgical treatment planning for intracranial AVM based on PCA images. By using PCA images, the irradiation doses for the vein areas were substantially reduced.

Transileocolic venous balloon dilatation for the management of primary and recurrent portal venous stenosis after living donor liver transplantation in children.

Portal venous stenosis is relatively a rare complication after liver transplantation in children and it sometimes leads to life threatening event due to gastrointestinal bleeding or graft failure. Recently, balloon dilatation has been widely accepted as a treatment of choice for the management of portal venous stenosis. The purpose of this study was to evaluate the feasibility of transileocolic venous balloon dilatation for the management of primary and recurrent portal venous stenosis after living donor liver transplantation (LDLT) in children. The records of 57 pediatric liver transplants were retrospectively reviewed. Nine patients (15.8%) with portal venous stenosis were identified. Seven symptomatic children with portal venous stenosis underwent balloon dilatation. Two approaches were employed for balloon dilatation; the transileocolic venous approach and the percutaneous transhepatic approach. In patients with recurrent stenosis, careful follow-up was carried out while they were asymptomatic. Twelve balloon dilatations were performed in seven children with primary or recurrent portal venous stenoses. The initial technical success rate was 91.7% (11/12), while 6 out of 12 (50.0%) procedures resulted in recurrent stenosis. Five out of six recurrent stenoses required repeated balloon dilatation. The clinical success rate of balloon dilatation in our study was 85.7% (6/7). Other than recurrent stenosis, two procedure-related complications occurred. In conclusion, transileocolic venous balloon dilatation was a safe and effective procedure for portal venous stenosis after LDLT in children.

Repeated transluminal endovascular Inoue stent graft placement for progressive dilatation of prosthetic graft that had been repaired with Inoue stent graft placement for dilatation 23 years after extraanatomical bypass.

A 76-year-old man had undergone aneurysm exclusion and ascending abdominal aortic extraanatomical bypass for a thoracoabdominal aortic aneurysm in 1978. In 1983 hemoptysis occurred, and resection and closure of the central stump of the aorta and a left lower lobectomy were performed. Dilatation (phi50 mm) of a prosthetic graft (Cooley Graft phi18 mm) used for extraanatomical bypass was noted in 2001 and was repaired by placement of an Inoue stent graft. However, the aneurysm diameter increased further (phi70 mm), although no endoleak was noted: Placement of an Inoue stent graft covering the whole length of the prosthetic graft was repeated in 2006. The postoperative course was smooth, no endoleak occurred, and the patient was discharged 2 weeks after surgery.

Can selective CT angiography reduce the incidence of severe complications during transcatheter arterial embolization or infusion chemotherapy for thoracic diseases?

PURPOSE: To evaluate the usefulness of selective computed tomography (CT) angiography in preventing severe complications, such as spinal cord injury and broncho- esophageal fistula, during the transcatheter arterial embolization or infusion chemotherapy for thoracic diseases. MATERIALS AND METHODS: Data from 28 patients with thoracic diseases were retrospectively analyzed in terms of selective CT angiography procedures carried out before transcatheter arterial embolization or transcatheter arterial infusion chemotherapy. RESULTS: There were no spinal cord injuries (0/13 and 0/15) or broncho-esophageal fistula developments (0/13 and 0/15) during transcatheter arterial embolization and transcatheter arterial infusion chemotherapy, respectively. CONCLUSION: We conclude that selective CT angiography is potentially useful for reducing the incidence of severe complications during transcatheter arterial embolization or infusion chemotherapy for thoracic diseases.

Use of gadolinium contrast adrenal venography for the assessment of primary aldosteronism in a patient with iodine allergy.

Primary aldosteronism is a relatively common cause of secondary hypertension. It is often important to diagnose this disease accurately, since appropriate surgical therapy may result in cure of the disease. Assessment of the laterality of adrenal hyperfunction is possible using adrenal venous sampling of steroid hormones, but this procedure may not be feasible in patients with allergy to iodinated radiocontrast agents. In this paper, we report a patient with primary aldosteronism who was found to have bilateral adrenal tumors on CT. Because preoperative localization of the hyperfunctioning tumor was important, adrenal venous sampling and venography was performed by a highly-experienced radiologist using the MRI contrast agent gadolinium. After reviewing the data, the patient received a right adrenalectomy. This case report demonstrates that it was possible to perform adrenal venography using gadolinium in this patient, however the safety and efficacy should be re-assessed in individual cases.

Intra-arterial CT-angiography for cerebral arteriovenous malformation--initial experiences for treatment planning of radiosurgery.

PURPOSE: To clarify the feasibility and effectiveness of intra-arterial CT angiography (IACTA) for treatment planning of arteriovenous malformation radiosurgery. METHODS AND MATERIALS: A CT scanner installed in an angiographic examination room was used. Helical IACTA was performed in 22 patients during continuous intra-arterial infusion of contrast medium via the internal carotid or vertebral artery, and dynamic IACTA was performed in 20 of these patients with reconstruction at 0.2-s intervals. The dynamic IACTA was repeated for each 3- or 5-mm increment to encompass the nidus. Subtractions were performed in postembolization cases. A retrospective review of IACTA was performed to assess the effectiveness of dynamic scans. RESULTS: No complications related to the angiographic procedure or CT imaging were detected. High contrast enhancement was obtained for both helical and dynamic IACTA. In 18 of the 20 cases (90%), draining veins were separated from the nidus by using the enhancement patterns, and in 13 cases (65%), feeding arteries were separated. CONCLUSION: Dynamic IACTA added important information for target-volume determinations. Conventional CT and MRI could be omitted from the protocol, and the period that patients wore the frame was substantially shortened. We conclude that IACTA is a practical and useful method for radiosurgical treatment planning of arteriovenous malformations.