Percutaneous Cholecystostomy Tube for Acute Cholecystitis: Quantifying Outcomes and Prognosis.

BACKGROUND: Percutaneous cholecystostomy tubes (PCT) are utilized in the management of acute cholecystitis in patients deemed unsuitable for surgery. However, the drive for these decisions and the outcomes remain understudied. We sought to characterize the practices and utilization of PCT and evaluate associated outcomes at an urban medical center. METHODS: Patients undergoing PCT placement over a 12-y study period ending May 2019 were reviewed. Demographics, clinical presentation, labs, imaging studies, and outcomes were abstracted. The primary and secondary outcomes were 30-d mortality and interval cholecystectomy, respectively. RESULTS: Two hundred and four patients met inclusion criteria: 59.3% were male with a median age of 67.5 y and a National Surgical Quality Improvement Program (NSQIP) risk of serious complication of 8.0%. Overall, 57.8% of patients were located in an intensive care unit setting. The majority (80.9%) had an ultrasound and 48.5% had a hepatobiliary iminodiacetic acid scan. The overall 30-d mortality was 31.9%: 41.5% for intensive care unit and 18.6% for ward patients (P < 0.01). Of patients surviving beyond 30 d (n = 139), the PCT was removed from 106 (76.3%), and a cholecystectomy was performed in 55 (39.6%) at a median interval of 58.0 d. A forward logistic regression identified total bilirubin (Adjusted Odds Ratio: 1.12, adjusted P < 0.01) and NSQIP risk of serious complication (Adjusted Odds Ratio: 1.16, adjusted P < 0.01) as the only predictors for 30-d mortality. CONCLUSIONS: Patients selected for PCT placement have a high mortality risk. Despite subsequent removal of the PCT, the majority of surviving patients did not undergo an interval cholecystectomy. Total bilirubin and NSQIP risk of serious complication are useful adjuncts in predicting 30-d mortality in these patients.

Comparing clinical outcomes of image-guided percutaneous transperitoneal and transhepatic cholecystostomy for acute cholecystitis.

BACKGROUND: Percutaneous cholecystostomy is performed by interventional radiologists for patients with calculous/acalculous cholecystitis who are poor candidates for cholecystectomy. Two anatomical approaches are widely utilized: transperitoneal and transhepatic. PURPOSE: To compare the clinical outcomes of transperitoneal and transhepatic approaches to cholecystostomy catheter placement. MATERIAL AND METHODS: From December 2007 to August 2015, 165 consecutive patients (97 men, 68 women) underwent either transperitoneal (n = 89) or transhepatic (n = 76) cholecystostomy at a single center. Indications were calculous cholecystitis (n = 21), acalculous cholecystitis (n = 35), hydrops (n = 1), gangrenous cholecystitis (n = 1), and other cholecystitis (n = 107). The most common high-risk co-morbidities were sepsis (n = 53) and cardiac (n = 11). Outcomes were compared using univariate and multivariable analysis. RESULTS: Post-procedure outcomes included tube dislodgement (transperitoneal [n = 6] and transhepatic [n = 3], P = 0.44), bile leak (transperitoneal [n = 5], transhepatic [n = 1], P = 0.14), gallbladder hemorrhage (transperitoneal [n = 2]; transhepatic [n = 3], P = 0.52), duodenal fistula (transperitoneal [n = 0], transhepatic [n = 1], P = 0.27), repeat cholecystostomy (transperitoneal [n = 1], transhepatic [n = 3], P = 0.27), and repeat cholecystitis requiring separate admission (transperitoneal [n = 6], transhepatic [n = 10], P = 0.15). All complications were Common Terminology Criteria for Adverse Events grade <3. Twenty transperitoneal patients underwent post-procedure cholecystectomy: 13 laparoscopic, three open, and four unclear/outside records. The mean time from cholecystostomy to operation was 38 days (range 3-211 days). Twenty-three transhepatic patients underwent cholecystectomy: 14 laparoscopic, eight open, and one unclear/outside records, with the mean time from cholecystostomy being 98 days (range 0-1053 days). One transhepatic and three transperitoneal patients died during admission. CONCLUSION: There were no significant differences in short-term complications after transperitoneal and transhepatic approaches to percutaneous cholecystostomy catheter placement.

Institutional decision to adopt Y90 as primary treatment for hepatocellular carcinoma informed by a 1,000-patient 15-year experience.

Yttrium-90 transarterial radioembolization (TARE) is a locoregional therapy (LRT) for hepatocellular carcinoma (HCC). In this study, we present overall survival (OS) outcomes in a 1,000-patient cohort acquired over a 15-year period. Between December 1, 2003 and March 31, 2017, 1,000 patients with HCC were treated with TARE as part of a prospective cohort study. A comprehensive review of toxicity and survival outcomes was performed. Outcomes were stratified by baseline Child-Pugh (CP) class, United Network for Organ Sharing (UNOS), and Barcelona Clinic Liver Cancer (BCLC) staging systems. Albumin and bilirubin laboratory toxicities were compared to baseline. OS outcomes were reported using censoring and intention-to-treat methodologies. All treatments were outpatient, with a median one treatment per patient. Five hundred six (51%) were CP A, 450 (45%) CP B, and 44 (4%) CP C. Two hundred sixty-three (26%) patients were BCLC A, 152 (15%) B, 541 (54%) C, and 44 (4%) D. Three hundred sixty-eight (37%) were UNOS T1/T2, 169 (17%) T3, 147 (15%) T4a, 223 (22%) T4b, and 93 (9%) N/M. In CP A patients, censored OS for BCLC A was 47.3 (confidence interval [CI], 39.5-80.3) months, BCLC B 25.0 (CI, 17.3-30.5) months, and BCLC C 15.0 (CI, 13.8-17.7) months. In CP B patients, censored OS for BCLC A was 27 (CI, 21-30.2) months, BCLC B 15.0 (CI, 12.3-19.0) months, and BCLC C 8.0 (CI, 6.8-9.5) months. Forty-nine (5%) and 110 (11%) patients developed grade 3/4 albumin and bilirubin toxicities, respectively. CONCLUSION: Based on our experience with 1,000 patients over 15 years, we have made a decision to adopt TARE as the first-line transarterial LRT for patients with HCC. Our decision was informed by prospective data and incrementally reported demonstrating outcomes stratified by BCLC, applied as either neoadjuvant or definitive treatment. (Hepatology 2017).

Contemporary Systematic Review of Health-Related Quality of Life Outcomes in Locoregional Therapies for Hepatocellular Carcinoma.

Health-related quality of life has become an important aspect in oncologic decision making. Recent data suggest that Health-Related Quality of Life (HRQoL) measurements can play an important prognostic role in patients with hepatocellular carcinoma (HCC). Locoregional therapies (LRTs) such as radiofrequency ablation, transarterial chemoembolization, and radioembolization (TARE) are important parts of HCC management. Results demonstrated that radiofrequency ablation treatment results in improving HRQoL compared to surgery for up to 3 years after treatment. Between TARE and transarterial chemoembolization, TARE provides the most benefit in terms of HRQoL. This systematic review investigated contemporary data surrounding HRQoL in patients undergoing LRTs and its impact on clinical decision making.

Angiogenic Response following Radioembolization: Results from a Randomized Pilot Study of Yttrium-90 with or without Sorafenib.

PURPOSE: To compare the regulation of serum angiogenic factors in patients with unresectable early hepatocellular carcinoma (HCC) treated with yttrium-90 ((90)Y) radioembolization alone vs with sorafenib. MATERIALS AND METHODS: In a single-center pilot study, 23 patients with unresectable HCC awaiting orthotopic liver transplantation were prospectively randomized to receive radioembolization alone (n = 12) or radioembolization with sorafenib (n = 11). Serum angiogenic markers (angiopoietin-2 [Ang-2], hepatocyte growth factor, interleukin [IL]-6, IL-8, c-reactive protein, platelet-derived growth factor [PDGF], and vascular endothelial growth factor [VEGF]) were assayed at baseline and at 2 and 4 weeks after radioembolization ((90)Y alone, n = 6; (90)Y plus sorafenib, n = 7). RESULTS: In the (90)Y-alone group, all growth factors were elevated above baseline levels at 2 and 4 weeks: VEGF increased 36% vs baseline at 2 weeks and 22% at 4 weeks, and PDGF increased 24% at 2 weeks and 3% at 4 weeks. In the (90)Y/sorafenib arm, Ang-2 and PDGF decreased at 2 weeks and the remainder increased. By 4 weeks, only PDGF remained below baseline levels. VEGF increased 49% at 2 weeks and 28% at 4 weeks, and PDGF decreased 31% at 2 weeks and 39% at 4 weeks. Differences were statistically significant for hepatocyte growth factor (P = .03) and PDGF (P = .02) at 2 weeks and for IL-6 (P = .05) at 4 weeks. CONCLUSIONS: Radioembolization is associated with a mild increase in angiogenic markers. The addition of sorafenib blunts PDGF response; other factors such as VEGF remain unaffected. The predominant effect of sorafenib may be through downregulation of PDGF and not VEGF.

Single- versus Triple-Drug Chemoembolization for Hepatocellular Carcinoma: Comparing Outcomes by Toxicity, Imaging Response, and Survival.

PURPOSE: To determine the efficacy of single- versus triple-drug chemoembolization for the treatment of hepatocellular carcinoma, as measured by toxicity, tumor response, time to progression (TTP), and overall survival (OS). MATERIALS AND METHODS: A single-center retrospective review was performed on 337 patients who underwent chemoembolization over a 14-year period; 172 patients underwent triple-drug conventional transarterial chemoembolization, and 165 patients underwent single-agent doxorubicin chemoembolization. Imaging characteristics and clinical follow-up after conventional transarterial chemoembolization were evaluated to determine TTP. Imaging response was determined per World Health Organization and European Association for the Study of Liver criteria. OS from time of first chemoembolization was calculated. RESULTS: Median TTP was similar between groups: 7.9 months (95% confidence interval [CI], 7.1-9.4) and 6.8 months (95% CI, 4.6-8.6) for triple- and single-drug regimens, respectively (P > .05). For single-agent conventional transarterial chemoembolization, median OS varied significantly by Barcelona Clinic for Liver Cancer (BCLC) stage: A, 40.8 months; B, 36.4 months; C, 10.9 months (P < .01). Median OS for triple-drug therapy also varied significantly by BCLC: A, 28.9 months; B, 18.1 months; C, 9.0 months (P < .01). Single-drug conventional transarterial chemoembolization demonstrated longer median OS compared with triple-drug therapy (P < .05) for BCLC A/B patients. CONCLUSIONS: Single-agent chemoembolization with doxorubicin and ethiodized oil demonstrates acceptable efficacy as measured by TTP and OS. Results compare favorably with traditional triple-drug therapy.

Dermatofibrosarcoma protuberans: is mohs surgery truly superior? And the success of tyrosine kinase inhibitors.

Dermatofibrosarcoma protuberans is a rare, slow growing tumor. This growth occurs most frequently in males from ages 20 to 50. The most common area on which DFSP originates is the trunk. DFSP presents clinically as a pink nodule or as a firm, flesh-colored to brown, indurated and exophytic plaque. Pathology shows atypical spindle cells of fibroblast origin surrounding a core of collagen. The definitive treatment of DFSP is surgical excision. Imatinib is a tyrosine kinase inhibitor that has been approved for use in DFSP refractory to surgery.

Rugby injury-associated pseudocyst of the auricle: report and review of sports-associated dermatoses of the ear.

PURPOSE: To describe a man with pseudocyst of the auricle, summarize the salient features of this condition, and review other sports-associated dermatoses of the ear. BACKGROUND: Pseudocyst of the auricle is an intracartilaginous collection of viscous straw-colored fluid typically located in the triangular fossa of the upper half of the auricle. It is usually asymptomatic. It can result in a permanent auricular deformity. MATERIALS AND METHODS: A 63-year-old man developed a pseudocyst of the auricle following a traumatic rugby-related injury to his left ear. The lesion has persisted for many years; chronic massage has slightly decreased its size. RESULTS: The etiology of pseudocyst of the auricle has been described as either traumatic or developmental. Our patient developed his pseudocyst after a rugby-related injury. This condition is usually unilateral. Aspirate of the content is usually sterile. Histology shows an intracartilaginous cyst devoid of an epithelial lining. Treatment involves either partial removal of the cartilage or chemical irritation to enhance adhesiveness. Subsequent compression (via button bolsters) minimizes recurrence. CONCLUSIONS: Pseudocyst of the auricle is a benign cystic dilatation, which is intracartilaginous, devoid of an epithelial lining, and may be traumatic or non-traumatic in origin. A man with rugby-associated trauma to his left ear developed this condition. Auricular pseudocyst can be added to the list of sports-associated dermatoses of the ear.

Perianal and periumbilical dermatitis: Report of a woman with group G streptococcal infection and review of perianal and periumbilical dermatoses.

PURPOSE: We describe a woman with perianal and periumbilical dermatitis secondary to group G Streptococcus, summarize the salient features of this condition, and review other cutaneous conditions that clinically mimic streptococcal dermatitis of the umbilicus. BACKGROUND: Periumbilical and perianal streptococcal dermatitis are conditions that commonly occur in children and usually result from beta-hemolytic group A Streptococcus. Rarely, non-group A streptococcal and staphylococcal infections have been reported in adults. MATERIALS AND METHODS: A 31-year-old woman developed perianal and periumbilical group G streptococcal dermatitis. Symptoms were present for six months and were refractory to clotrimazole 1 percent and betamethasone dipropionate 0.05 percent cream. RESULTS: The etiology of perianal and periumbilical dermatitis is unclear, but is perhaps explained by virulence of previously asymptomatic colonized bacteria. Perianal streptococcal dermatitis is more common in children. A number of adult infections have been reported, most of which were secondary to group A beta-hemolytic Streptococcus. Men are more often affected than women. Group G Streptococcus is rarely the infective etiology of perianal streptococcal dermatitis. This condition presents as a superficial well demarcated erythematous patch on clinical examination. Diagnosis is ascertained by diagnostic swabs and serological tests: antistreptolysin O (ASO) or anti-DNase titer. Treatments include oral amoxicillin, penicillin, erythromycin, and mupirocin ointment. CONCLUSIONS: Our patient expands on the clinical presentation typical of streptococcal dermatitis. We describe a rare occurrence of an adult woman infected with non-group A Streptococcus. Several conditions can mimic the presentation of perianal streptococcal dermatitis. Although rare, group G Streptococcus should be considered in the setting of virulent infections usually attributed to group A species. Streptococcal dermatitis can be added to the list of conditions affecting the umbilicus.

Pretransplant Intra-arterial Liver-Directed Therapy Does Not Increase the Risk of Hepatic Arterial Complications in Liver Transplantation: A Single-Center 10-Year Experience.

PURPOSE: To investigate the association between pretransplant intra-arterial liver-directed therapy (IAT) for hepatocellular carcinoma (HCC) and hepatic arterial complications (HAC) in orthotopic liver transplantation (OLT) [namely hepatic artery thrombosis (HAT) and/or the need for hepatic arterial conduit]. METHODS: A total of 175 HCC patients (mean age: 60 years) underwent IAT with either transarterial chemoembolization or yttrium-90 (90Y) transarterial radioembolization prior to OLT between 2003 and 2013. A matched control cohort of 159 HCC patients who underwent OLT without prior IAT was selected. Incidence of HAC in both cohorts was investigated. The categorical differences between both cohorts were calculated by chi-square test. RESULTS: Among the 175 patients (chemoembolization, n = 82; radioembolization, n = 93), 8 (5%) required conduits due to HA disease (chemoembolization, n = 6; radioembolization, n = 2), 3 (2%) developed HAT (chemoembolization, n = 2; radioembolization, n = 1). Eleven of 175 patients (6.7%) had HAC. Of the 159 control patients, 6 (4%) needed conduits for HA disease and 3 (2%) developed HAT. Nine of 159 patients (5.7%) had HAC. Chi-square analysis between the IAT cohort and the control group yielded a p value of 0.810. When comparing chemoembolization to radioembolization, p = 0.076 (not significant at p < 0.05). CONCLUSION: Although aggressive pretransplant radioembolization and chemoembolization are both utilized in most liver transplant centers, neither appears to increase the risk of peri-transplant hepatic arterial complications in HCC patients.

Ticks and Tick Bites Presenting as "Funny Moles": A Review of Different Presentations and a Focus on Tick-borne Diseases.

Purpose: To describe a man with an adherent tick mimicking a melanoma, summarize the salient features of this condition, and review other cases of ticks mistaken for dermatoses. Background: Ticks are obligatory ectoparasites. Disease-causing ticks belong to two families: Ixodidae (hard ticks) and Argasidae (soft ticks). Ticks thrive by consuming blood from animal hosts, and the transfer of infected blood from one host to the next is the method by which ticks spread disease. Materials and methods: The authors describe a man who presented to their dermatology clinic in New York with an unusual black pigmented lesion on the right zygomatic region of his face. He was worried about how rapidly the lesion had developed and the tingling of the skin surrounding it. Since the patient had a history of nonmelanoma skin cancer, he was concerned that the lesion was a melanoma. An excisional biopsy of the lesion revealed a non-Ixodes tick with a surrounding tick-bite reaction. Results: Ticks cause cutaneous manifestations through physical trauma and their salivary contents. A number of reports describe a similar phenomenon of a persistent tick being mistaken for a nodule or tumor. Management includes complete removal of a tick, either mechanically or surgically, along with the appropriate work-up for tick-borne diseases in the relevant geographic location. The decision to test for systemic disease depends on the clinical presentation of the patient and geographic location of the tick bite. Conclusion: A patient presented to the authors' dermatology clinic with a pigmented lesion suspicious for a melanoma, but the lesion was actually an adherent non-Ixodes tick. This case illustrates the importance of keeping insects and arthropods in the differential diagnosis of a sudden- and recent-onset pigmented skin lesion.

Paraneoplastic palmoplantar keratoderma secondary to metastatic uterine adenocarcinoma.

Palmoplantar keratoderma (PPK) is a dermatosis that presents as hyperkeratosis of the palms and soles. It may be acquired or heritable. Acquired PPK often occurs as a paraneoplastic response as well as a stigma of other dermatoses. We report a rare case of a 72-year-old woman with acquired PPK secondary to metastatic uterine adenocarcinoma. We also review other rare cases of cutaneous paraneoplasia secondary to uterine cancer and describe the salient features of acquired PPK. Acquired PPK most commonly presents as a paraneoplastic response to visceral malignancies that include localized esophageal, pulmonary, urinary/bladder, and gastric carcinomas, as well as myeloma. Management of acquired PPK includes treatment of the underlying cause. Adjunctive vitamin A analogues have been found to be effective.

Fully Regressive Melanoma: A Case Without Metastasis.

Fully regressive melanoma is a phenomenon in which the primary cutaneous melanoma becomes completely replaced by fibrotic components as a result of host immune response. Although 10 to 35 percent of cases of cutaneous melanomas may partially regress, fully regressive melanoma is very rare; only 47 cases have been reported in the literature to date. AH of the cases of fully regressive melanoma reported in the literature were diagnosed in conjunction with metastasis on a patient. The authors describe a case of fully regressive melanoma without any metastases at the time of its diagnosis. Characteristic findings on dermoscopy, as well as the absence of melanoma on final biopsy, confirmed the diagnosis.

New Developments in Interventional Oncology: Liver Metastases From Colorectal Cancer.

Colorectal cancer is the third leading cause of cancer death in the United States. Although hepatic excision is the first-line treatment for colorectal liver metastasis (CRLM), few patients are candidates. Locoregional therapy (LRT) encompasses minimally invasive techniques practiced by interventional radiology. These include ablative treatments (radiofrequency ablation, microwave ablation, and cryosurgical ablation) and transcatheter intra-arterial therapy (hepatic arterial infusion chemotherapy, transarterial "bland" embolization, transarterial chemoembolization, and radioembolization with yttrium 90). The National Comprehensive Cancer Network recommends LRT for unresectable CRLM refractory to chemotherapy. The following is a review of LRT in CRLM, including salient features, advantages, limitations, current roles, and future considerations.