Management of angiogram-negative acute colonic hemorrhage: safety and efficacy of colonoscopy-guided superselective embolization.

BACKGROUND: We evaluated the efficacy and safety of superselective embolization with assistance of colonoscopy for acute colonic hemorrhage. METHODS: Of 92 cases of acute colonic hemorrhage requiring colonoscopic intervention, 11 (12 %) could not be successfully treated. Of these, 10 patients (9 men, mean age 65.5 years, range 39-75 years) underwent superselective embolization. Hemorrhage was caused by diverticular disease (n = 8), polypectomy (n = 1), and vascular malformation (n = 1). In all 10 cases, the radiopaque clips were placed at the bleeding point via colonoscopy. Microcatheters were used in all procedures, and embolization was performed at the level of the vasa recta leading to or near the clips with Gelfoam particles, microcoils, or both. RESULTS: Immediate hemostasis was achieved in all patients. In 6 of 10 patients (60 %), selective angiograms showed no active extravasation at the time of the procedure and the embolization was performed using clips as a landmark. In the remaining four patients, selective angiograms showed active extravasation from the vasa recta leading to the clips. The mean number of embolized vessels with no active extravasation and with active extravasation was 1.83 (range 1-3) and 1.25 (range 1-2), respectively. The mean duration of clinical follow-up was 11.6 months (range 1-29 months). One patient (10 %) bled from a different site than the treated site a month after embolization, but the bleeding ceased after endoscopic intervention. All the patients (100 %) were evaluated for objective evidence of ischemia by colonoscopy. Four of the 10 patients (40 %) were found endoscopically to have small areas of ischemia involving only the mucosa, but they remained asymptomatic. There was no bowel infarction or stricture. CONCLUSIONS: Colonoscopy-assisted superselective embolization may be a safe and useful procedure for acute colonic hemorrhage without active extravasation on angiogram.

Therapeutic efficacy of intra-arterial docetaxel and nedaplatin infusion concomitant with radiotherapy for T4 maxillary sinus squamous cell carcinoma.

The aim of this study was to evaluate the efficacy of intra-arterial chemoradiotherapy with docetaxel and nedaplatin for T4 maxillary sinus squamous cell carcinoma (MSSCC). Data were retrospectively analysed for 22 consecutive patients with T4 MSSCC who underwent intra-arterial chemoradiotherapy. Participants received intensity-modulated radiotherapy (70 Gy in 35 fractions) concomitantly with docetaxel (60 mg/m2) and nedaplatin (80 mg/m2) administered every 4 weeks for a total of three sessions. The median follow-up period was 49 months (range 12-91 months). T4a tumours were found in 16 patients (73%) and T4b tumours in six patients (27%). Cervical metastasis was found in nine patients (41%; five N2b, four N2c). The 5-year loco-regional control, disease-free survival, and overall survival rates for patients with T4a disease were 92.3%, 92.3%, and 90.3%, respectively, compared to 83.3% (P = 0.42), 66.7% (P = 0.07), and 83.3% (P = 0.46), respectively, for those with T4b disease. The 5-year loco-regional control, disease-free survival, and overall survival rates for patients with cervical lymph node metastasis were all 87.5% compared to 92.3% (P = 0.86), 84.6% (P = 0.69), and 92.3% (P = 0.93), respectively, for those without cervical metastasis. Intra-arterial chemoradiotherapy with docetaxel and nedaplatin may provide favourable loco-regional control and increased survival in T4 MSSCC.

Temporal Profiles of Symptom Scores After Palliative Radiotherapy for Bleeding Gastric Cancer With Adjustment for the Palliative Prognostic Index: An Exploratory Analysis of a Multicentre Prospective Observational Study (JROSG 17-3).

AIMS: Although palliative radiotherapy for gastric cancer may improve some symptoms, it may also have a negative impact due to its toxicity. We investigated whether symptoms improved after radiotherapy with adjustment for the Palliative Prognostic Index (PPI) considering that patients with limited survival tend to experience deterioration of symptoms. MATERIALS AND METHODS: This study was an exploratory analysis of the Japanese Radiation Oncology Study Group study (JROSG 17-3). We assessed six symptom scores (nausea, anorexia, fatigue, shortness of breath, pain at the irradiated area and distress) at registration and 2, 4 and 8 weeks thereafter. We tested whether symptoms linearly improved after adjusting for the baseline PPI. Shared parameter models were used to adjust for potential bias in missing data. RESULTS: The present study analysed all 55 patients enrolled in JROSG 17-3. With time from registration as the only explanatory variable in the model, a significant linear decrease was observed in shortness of breath, pain and distress (slopes, -0.26, -0.22 and -0.19, respectively). Given that the interaction terms (i.e. PPI × time) were not significantly associated with symptom scores in any of the six symptoms, only PPI was included as the main effect in the final multivariable models. After adjusting for the PPI, shortness of breath, pain and distress significantly improved (slope, -0.25, -0.19 and -0.17; P < 0.001, 0.002 and 0.047, respectively). An improvement in fatigue and distress was observed only in patients treated with a biologically effective dose ≤14.4 Gy. CONCLUSION: Shortness of breath, pain and distress improved after radiotherapy. Moreover, a higher PPI was significantly associated with higher symptom scores at all time points, including baseline. In contrast, PPI did not seem to influence the improvement of these symptoms. Regardless of the expected survival, patients receiving radiotherapy for gastric cancer can expect an improvement in shortness of breath, pain and distress over 8 weeks. Multiple-fraction radiotherapy might hamper the improvement in fatigue and distress by its toxicity or treatment burden.

Efficacy of hepatic arterial infusion of prostaglandin E1 in the treatment of postoperative acute liver failure--report of a case.

Prostaglandin E1 (PGE1) has received attention for its protective effects against various types of liver damage. However, it is known that approximately 70% of PGE1 is inactivated during a single passage through the lung. Therefore, direct infusion of PGE1 into the liver bloodstream is preferable to intravenous infusion. A 66-year-old man with hepatocellular carcinoma with liver cirrhosis developed postoperative acute liver failure following posterior segmentectomy under hepatic total vascular exclusion exceeding 1 hour. Because his liver function did not recover in spite of plasma exchange starting on postoperative day 8 and intravenous infusion of PGE1, hepatic arterial continuous infusion of PGE1 at a rate of 0.01 microgram/kg/min was carried out for 7 days from postoperative day 17. Immediately after the start of the arterial infusion, the bile flow significantly increased compared to before the arterial infusion, and the serum total bilirubin level decreased thereafter and finally recovered from the hepatic failure. In addition to its highly efficient drug delivery, the hepatic arterial infusion of PGE1 seems to be more advantageous in oxygen delivery to the liver compared with intravenous infusion. In conclusion, the hepatic arterial infusion of PGE1 may be useful in the treatment of acute liver failure.

Small cell carcinoma of the lung: CT findings of parenchymal lesions.

PURPOSE: The purpose of this study was to describe the CT findings of small cell carcinoma of the lung. MATERIALS AND METHODS: CT findings were retrospectively reviewed in 38 patients (34 men, 4 women; aged 46-73 years) with pathologically proven small cell carcinoma. RESULTS: Tumors were located centrally in 23 cases (61%) and peripherally in 15 cases (39%). Twenty-seven patients had a bulky central mass with encasement of the great vessels or extrinsic compression of the airway (22 central tumors, 5 peripheral tumors). Six patients had peripheral lesions without adenopathy. Five peripheral small cell carcinomas demonstrated peribronchial thickening adjacent to the primary tumor. CONCLUSION: The first sign of small cell carcinoma most typically is a bulky central mass that represents metastasis to the hilar and/or mediastinal lymph nodes. Although no findings specific to peripheral small cell carcinoma are available, small cell carcinoma originating from the peripheral lung parenchyma should be included in the differential diagnosis when peribronchial thickening is associated with the tumor.

Malignant paraganglioma draining into the main portal vein.

Abdominal paraganglioma is a relatively rare tumor, and there have been no previous reports describing its contrast-enhanced ultrasonographic findings. We report a case of a lesion of unknown origin incidentally detected by ultrasound in the right upper abdomen. The lesion was markedly hypervascular and contrast-enhanced ultrasonogram showed it to be communicating with the portal vein. This communication was then confirmed by angiogram. Such an arteriovenous communication through paraganglioma has been recently reported, and a diagnosis of a paraganglioma should be considered when contrast-enhanced ultrasonogram shows a solid mass of unknown origin draining directly into the venous system.

Successful treatment of a ruptured infected aneurysm of the lumbar artery with transcatheter embolization.

We report a patient who had an infected aneurysm of the lumbar artery caused by prolonged psoas abscess-forming spondylitis due to methicillin-resistant Staphylococcus aureus and who was treated successfully with transcatheter arterial embolization. This case suggests that an infected aneurysm can be treated successfully by transcatheter arterial embolization in emergent situations (active bleeding or septicemia) even if surgery is contraindicated.

Segmental high intensity on T1-weighted hepatic MR images.

BACKGROUND: We investigated the diagnostic importance of segmental high-intensity (SHI) areas not corresponding to mass lesions on T1-weighted magnetic resonance (MR) images. METHODS: We conducted a retrospective investigation of hepatic MR images obtained from 634 patients during a 4-year period at our institution. Images were compared with findings reported in the patients' medical records. There were 16 patients (2.5%) with SHI areas not corresponding to a mass lesion. We compared MR images with plain computed tomographic (CT) scans (n = 16), angiograms (n = 12), and histologic findings (n = 10). RESULTS: The segments with intrahepatic bile duct dilatation showed hyperintensity on T1-weighted images. In six of 16 patients, the biliary duct was more dilated in the area of hyperintensity than in areas without hyperintensity. The SHI areas appeared as areas of low attenuation (n = 13), high attenuation (n = 1), or isoattenuation (n = 2) on plain CT scans. Histologically, these areas showed ductular proliferation and deposition of bile pigment within the hepatocytes. CONCLUSION: Segmental areas of increased signal intensity on T1-weighted images were probably due to intrahepatic cholestasis.

Portal flow into the liver through veins at the site of biliary-enteric anastomosis.

The aim of this study was to establish the role played by jejunal veins in hepatopetal flow after biliary-enteric anastomosis and to evaluate the helical CT features of hepatopetal flow through the anastomosis. We retrospectively analyzed helical CT images of the liver in 31 patients with biliary-enteric anastomosis who underwent hepatic angiography with (n=13) or without (n=18) CT arterial portography within 2 weeks of the CT examination during the last 4 years. Arterial portography showed hepatopetal flow through small vessels located (communicating veins) between the elevated jejunal veins and the intrahepatic portal branches in two (9%) of 22 patients with a normal portal system. Helical CT showed focal parenchymal enhancement around the anastomosis in these two patients. All nine patients with extrahepatic portal vein occlusion (100%) had hepatopetal flow through the anastomosis, and four of the nine had decreased portal flow. CT revealed small communicating veins in two of these four patients. In five patients with normal portal perfusion despite extrahepatic portal vein occlusion, CT detected dilated communicating veins and elevated jejunal veins. The presence of communicating veins and/or focal parenchymal enhancement around the anastomosis indicates hepatopetal flow through the elevated jejunal veins.

The feasibility of retrograde catheterization of the right gastric artery via the left gastric artery.

Retrograde catheterization of the right gastric artery was attempted in 22 patients for the purpose of proximal right gastric artery embolization. Retrograde catheterization was successfully performed in 12 of the 14 patients (86%) with smooth anastomoses. Retrograde catheterization was unsuccessful (n = 1) or time-consuming (n = 1) in two patients (14%) with smooth anastomoses. Right gastric artery embolization was successfully performed with microcoils in 13 of the patients. In all eight patients with tortuous anastomoses, catheterization was unsuccessful. Retrograde catheterization should be considered possible when preliminary angiography indicates a smooth anastomosis with the left gastric artery.

The CT findings of pulmonary sarcoidosis.

We analyzed the CT findings in 35 patients with pulmonary sarcoidosis. Twenty-seven patients had biopsy-proven sarcoidosis; in eight patients the diagnosis was made clinically. In all the 35 patients, 10-mm collimation scans were available. In seven patients, high-resolution CT was also obtained. Twenty-eight patients had lymphadenopathy associated with pulmonary infiltration, two patients had pulmonary infiltration without lymphadenpathy, five patients had lymphadenopathy alone. The most frequent parenchymal features on CT were small nodules (100%) and irregularly thickened bronchovascular bundle (90%). Other frequent CT findings were pleural or subpleural thickening (83%), septal lines (73%) and ground-glass attenuation (63%). In all cases, small nodules were associated with other lesions. The authors conclude that in patients with sarcoidosis, CT is a valuable technique to visualize the findings in the pulmonary parenchyma characteristic enough to allow confident diagnosis. While high-resolution CT is superior in the assessment of linear opacities and cysts, conventional CT is superior in demonstrating small nodular opacities. We believe that both should be combined in the examination of patients with sarcoidosis.

Pulmonary CT findings in acute mercury vapour exposure.

AIM: We describe the pulmonary computed tomography (CT) findings in acute mercury poisoning. MATERIALS AND METHODS: Initial (n= 8) and follow-up (n= 6) chest CT examinations in eight patients exposed to mercury vapour while cutting pipes in a sulphuric acid plant were reviewed. Of the eight patients, two were asymptomatic and had normal CT results, two were asymptomatic but had abnormalities on CT, and four had both acute symptoms and positive CT results. The patients were all men whose ages ranged from 37 to 54 years (mean, 49 years). RESULTS: Poorly defined nodules were present in five of six patients with positive CT findings, present alone in two patients or as part of a mixed pattern in three. They were random in distribution. Alveolar consolidation (n= 3) and areas of ground-glass opacity (n= 4) were observed and were more prominent in the most severely affected patients with the highest blood and urine level of mercury, predominantly in the upper and/or middle zone. These abnormal findings on CT resolved with (n= 1) or without (n= 5) steroid therapy. Pathological findings (n= 1) demonstrated acute interstitial changes predominantly with oedema. CONCLUSION: We report CT findings in eight patients acutely exposed to mercury vapour. The pulmonary injury was reversible on CT in these cases. Hashimoto, M. (2001). Clinical Radiology56, 17-21.

Internal mammary artery embolization for hemoptysis.

PURPOSE: The purpose of this study was to determine the factors influencing development of blood supply from the internal mammary artery and to discuss the value of embolization of the abnormal branches from this vessel using small particles following occlusion of the normal distal branches using microcoils in treating hemoptysis. MATERIAL AND METHODS: Five patients with hemoptysis underwent internal mammary artery embolization with coaxial microcatheter systems. Bronchoscopy, chest radiographs, and CT were performed to determine the site and extent of the basic disease before embolotherapy in all patients. RESULTS: In all patients, pulmonary lesions had extended from the lung to the adjacent pleural surface at the anterior lung field. Four patients underwent embolization from the proximal portion of the internal mammary artery following distal coil embolization. One patient who underwent only proximal embolization had recurrent bleeding. CONCLUSION: The internal mammary artery contributes to the perfusion of lesions responsible for hemoptysis when the basic lesion involves the pulmonary parenchyma adjacent to the anterior pleural surface. Initial distal occlusion of the internal mammary artery may improve the efficacy of embolization of this artery for hemoptysis.