SIRM-SIN-AIOM: appropriateness criteria for evaluation and prevention of renal damage in the patient undergoing contrast medium examinations-consensus statements from Italian College of Radiology (SIRM), Italian College of Nephrology (SIN) and Italian Association of Medical Oncology (AIOM).

The increasing number of examinations and interventional radiological procedures that require the administration of contrast medium (CM) in patients at risk for advanced age and/or comorbidities highlights the problem of CM-induced renal toxicity. A multidisciplinary group consisting of specialists of different disciplines-radiologists, nephrologists and oncologists, members of the respective Italian Scientific Societies-agreed to draw up this position paper, to assist clinicians increasingly facing the challenges posed by CM-related renal dysfunction in their daily clinical practice.The major risk factor for acute renal failure following CM administration (post-CM AKI) is the preexistence of renal failure, particularly when associated with diabetes, heart failure or cancer.In accordance with the recent guidelines ESUR, the present document reaffirms the importance of renal risk assessment through the evaluation of the renal function (eGFR) measured on serum creatinine and defines the renal risk cutoff when the eGFR is < 30 ml/min/1.73 m2 for procedures with intravenous (i.v.) or intra-arterial (i.a.) administration of CM with renal contact at the second passage (i.e., after CM dilution with the passage into the pulmonary circulation).The cutoff of renal risk is considered an eGFR < 45 ml/min/1.73 m2 in patients undergoing i.a. administration with first-pass renal contact (CM injected directly into the renal arteries or in the arterial district upstream of the renal circulation) or in particularly unstable patients such as those admitted to the ICU.Intravenous hydration using either saline or Na bicarbonate solution before and after CM administration represents the most effective preventive measure in patients at risk of post-CM AKI. In the case of urgency, the infusion of 1.4% sodium bicarbonate pre- and post-CM may be more appropriate than the administration of saline.In cancer patients undergoing computed tomography, pre- and post-CM hydration should be performed when the eGFR is < 30 ml/min/1.73 m2 and it is also advisable to maintain a 5 to 7 days interval with respect to the administration of cisplatin and to wait 14 days before administering zoledronic acid.In patients with more severe renal risk (i.e., with eGFR < 20 ml/min/1.73 m2), particularly if undergoing cardiological interventional procedures, the prevention of post-CM AKI should be implemented through an internal protocol shared between the specialists who treat the patient.In magnetic resonance imaging (MRI) using gadolinium CM, there is a lower risk of AKI than with iodinated CM, particularly if doses < 0.1 mmol/kg body weight are used and in patients with eGFR > 30 ml/min/1.73 m2. Dialysis after MRI is indicated only in patients already undergoing chronic dialysis treatment to reduce the potential risk of systemic nephrogenic fibrosis.

Role of Cone-Beam CT in the Intraprocedural Evaluation of Chemoembolization of Hepatocellular Carcinoma.

PURPOSE: To assess the ability of Cone-Beam CT (CBCT), performed during the Transcatheter Arterial Chemoembolization (TACE), in predicting the response to treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: We evaluated fifty patients (M/F = 40/10, mean age: 66.7 years ± 8.22) with hepatocellular carcinoma (HCC), for a total of 82 nodules evaluated (mean diameter: 21.4 ± 11 mm). All patients performed a CT scan one month before and one month after TACE. After TACE is completed, a CBCT was performed to assess the degree of drug retention in the lesions. For each lesion, the major diameter, volume, and density of the vital portion were evaluated. The response to TACE was assessed using the mRECIST criteria on the CT scan carried out one month after the procedure. The receiver operating characteristic (ROC) curves were performed to assess the accuracy of the CBCT in predicting the response to treatment and to identify the cut-off points for each parameter under examination. RESULTS: A complete response (CR) was observed in 24/50 patients (48%), a partial response (PR) in 16/50 (32%), stable disease (SD) in 8/50 (16%), and progressive disease (PD) in 2/50 (4%). Evaluation of the area under the ROC curve showed that the diameter, volume, and density of the lesion, measured with CBTC, had an accuracy of 94%, 96%, and 98%, respectively, in discriminating a complete response from a not complete response. CONCLUSION: CBCT is effective in predicting short-term response at 1-month follow-up of HCC treated by chemoembolization.

Degradable starch microspheres transarterial chemoembolization (DSMs-TACE) in patients with unresectable hepatocellular carcinoma (HCC): long-term results from a single-center 137-patient cohort prospective study.

PURPOSE: To evaluate safety and efficacy of degradable starch microspheres (DSMs) TACE in a large clinical cohort of patients with unresectable HCC. MATERIALS AND METHODS: This is a single-center consecutive patients cohort study. The study was approved by local institutional ethics committee. Written informed consent was obtained. From December 2013 to March 2018, 137 cirrhotic patients with unresectable HCC were enrolled. For DSMs-TACE, a mixture of 4 mL of DSMs, 6 mL of non-ionic contrast and doxorubicin at a dose of 50 mg/m2 were used. Primary end point was long-term outcome, in terms of time to progression (TTP) and overall survival (OS). Secondary endpoints were: safety, liver toxicity, 1-month percentage of tumor necrosis according to the modified RECIST criteria. RESULTS: Two hundred and sixty-seven DSMs-TACE were performed in 137 HCC patients (33 patients in BCLC stage A, 84 patients in BCLC stage B, and 20 in stage C). Patients had a mean nodule number of 3.5 ± 1.2 (SD). Major complications were observed in 6.8% of cases. Post-embolization syndrome was common (101 patients 73.7%). According to mRecist criteria, a high objective response rate was obtained even after just one treatment (84.3% of patients showed complete response or partial response). The median TTP and OS after DSMs-TACE were 12 months and 36 months, respectively. OS at 6 months, 1 year, 2 and 3 years was 98%, 81.3%, 57.9%, 34.9%, respectively. CONCLUSION: DSMs-TACE is a safe and effective therapy for patients with HCC, allowing to obtain a good rate of OS with excellent local tumor control.

Vascular anomalies of the celiac trunk and implications in treatment of HCC with TACE. Description of a case and review of the literature.

Knowledge of the vascular anatomy of the upper abdomen is important in the daily practice of surgeons specialized in the hepatobiliary and pancreatic area, and for general surgeons and radiologists, mainly those involved in interventional radiology. Since anatomical variants of the celiac axis and hepatic arteries are common, an accurate description of vascularization is required before procedures to avoid iatrogenic vascular changes. We reported a case of a young male patient with HBV related cirrhosis, who came to our institution for the treatment of 2 HCC nodules. The preprocedural contrast-enhanced CT examination showed combined variations of celiac trunk, hepatic arteries, gastroduodenal artery, and right inferior phrenic artery. The careful pre- and intraprocedural evaluation of vascularization allowed us to perform transarterial chemoembolization of the 2 nodules without complications. The incidence and developmental and clinical significance of this variation is discussed with a detailed review of the literature. Knowledge of such a case has important clinical significance in abdominal operations or invasive arterial procedures.

Evaluation of Contrast-Enhanced Intraoperative Ultrasound in the Detection and Management of Liver Lesions in Patients with Hepatocellular Carcinoma.

AIM: To evaluate the role of contrast-enhanced intraoperative ultrasound (CE-IOUS) during liver surgery in the detection and management of liver lesions in patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS: From December 2016 to December 2017, 50 patients with HCC, who were candidates for liver resection, were evaluated with intraoperative ultrasound (IOUS). For all patients, MRI and/or CT were performed before surgery. During surgery, IOUS was performed after liver mobilization, and when nodules that had not been detected in the preoperative MRI and/or CT were observed, CE-IOUS scans were carried out with the dual purpose of better characterizing the unknown lesion and discovering new lesions. RESULTS: In 12 patients, IOUS showed 14 nodules not detected by preoperative MRI and/or CT, before surgery. Out of the 12 lesions, five presented vascular features compatible with those of malignant HCC to the evaluation with CE-IOUS and four of these were simultaneously treated with intraoperative radiofrequency ablation (RFA). The fifth lesion was resected by the surgeon. The remaining nine lesions recognized by IOUS were evaluated as benign at CE-IOUS and considered regenerative nodules. The last diagnosis was confirmed during follow-up obtained by means of CT and/or MRI after 1, 3, 6, or 12 months. CONCLUSION: In our experience, CE-IOUS is a useful diagnostic tool in both benign pathologies, such as regenerative nodules, and malignant liver lesions. The advantage of this approach is the possibility of intraoperatively characterizing, based on vascularization patterns, lesions that could not be diagnosed by preoperative imaging, resulting in modification of the surgical therapy decision and expansion of the resection or intraoperative ablation.

Rare malignant glomus tumor of the stomach with liver metastases.

We report a case of a 72-year-old male admitted in our Unit with anemia and a 10 cm liver neoplasm. Computed tomography scan showed 2 lesions respectively in the II, III and, VIII segment of the liver. Surgical resection of the larger liver mass was performed and the tumor appeared as a solid-cystic mass and a diagnosis of malignant mesenchymal tumor not otherwise specified, was made. One month later a Computed tomography scan detected a dishomogeneous gastric mass, 6 cm in diameter, in the greater curvature, confirmed by esophagogastroduodenoscopy. The pathological diagnosis from endoscopic biopsy revealed a mesenchymal tumor requiring surgical removal for accurate diagnosis. The patient underwent relaparotomy and gastric resection and the pathological findings gave a diagnosis of a rare malignant glomic tumor of the stomach confirmed by the revision of previously performed hepatic resection classified as secondary lesion.