Outcomes of Adrenal Venous Sampling in Patients with Bilateral Adrenal Masses and ACTH-Independent Cushing's Syndrome.

BACKGROUND: Management of patients with bilateral adrenal masses and ACTH-independent Cushing's syndrome (AICS) is challenging, as bilateral adrenalectomy can lead to steroid dependence and lifelong risk of adrenal crisis. Adrenal venous sampling (AVS) has been previously reported to facilitate lateralization for guiding adrenalectomy. The aim of the current study was to investigate the utility of AVS using protocol from study by Young et al. in the management of patients with bilateral adrenal masses and AICS. METHODS AND DESIGN: A retrospective review of all patients with bilateral adrenal masses and AICS who underwent AVS from 2008 to 2016 was performed. AVS for cortisol and epinephrine was performed with dexamethasone suppression. The adrenal vein to peripheral vein cortisol ratios and side-to-side cortisol lateralization ratios were calculated. RESULTS: AVS was successful in 8 of 9 patients. All 8 patients had AVS results indicating bilateral cortisol hypersecretion. Six patients underwent adrenalectomy: 3 had unilateral adrenalectomy of the larger size mass, 2 had bilateral adrenalectomy (both sides >4 cm.) and 1 had stepwise bilateral adrenalectomy. Final pathology revealed macronodular adrenal hyperplasia in all 6 patients that underwent surgery. CONCLUSION: AVS was useful in excluding a unilateral adenoma as the source of AICS in this study of patients with bilateral adrenal masses and AICS. However, adrenal mass size influenced surgical decision making more than AVS results. More data are needed before AVS can be advocated as essential for management of patients with bilateral adrenal masses and AICS.

Hepatic artery infusion of melphalan in patients with liver metastases from ocular melanoma.

BACKGROUND AND OBJECTIVES: Ocular melanoma has a predilection for liver metastases. Systemic treatment is ineffective and the optimal regional therapy approach is poorly defined. Isolated hepatic perfusion (IHP) with melphalan has emerged as a viable treatment option, however a subset of patients are not candidates for this treatment. We therefore sought to determine if melphalan could be safely administered via the hepatic artery for these patients. METHODS: A retrospective review of patients treated with hepatic artery infusion (HAI) of melphalan was undertaken. All patients had contraindications to IHP and were without other therapy options. Melphalan infusion was repeated every four weeks with consideration for dose escalation in the absence of toxicity or significant disease progression. RESULTS: Fourteen patients were treated with HAI of melphalan from 2010 to 2015. All patients had hepatic dysfunction or prohibitive tumor volume precluding IHP. There were no procedure-related complications. Three patients (21%) died within 30 days and the median survival was 2.9 months. Elevated baseline bilirubin > 2.5 mg/dL was associated with worse overall survival (0.93 vs 6.3 months, P < 0.05). CONCLUSION: HAI of melphalan is safe and feasible for patients with metastatic ocular melanoma. Further study to determine the optimal utilization of this treatment approach is warranted.

Covered Stents and Coil Embolization for Treatment of Postpancreatectomy Arterial Hemorrhage.

PURPOSE: To evaluate the efficacy and clinical outcomes associated with stent-graft placement and coil embolization for postpancreatectomy arterial hemorrhage (PPAH). MATERIALS AND METHODS: Retrospective review of 38 stent-graft and/or embolization procedures in 28 patients (23 men; mean age, 65.1 y) for PPAH between 2007 and 2014 was performed. Time of bleeding, source of hemorrhage, intervention and devices used, repeat intervention rate, time to recurrent bleeding, complications, and 30-day mortality were assessed. Independent risk factors for recurrent bleeding and 30-day mortality were identified. RESULTS: Median onset of hemorrhage was at 39 days (mean, 27.9 d; range, 5-182 d). Covered stents were used in 65.7% of interventions, coil embolization in 23.6%, stent-assisted embolization in 5.2%, and stent-graft angioplasty in 2.6%. A total of 28 stent-grafts were placed, of which 19 were self-expandable and nine were balloon-mounted. Mean stent-graft diameter was 6.6 mm (range, 5-10 mm). Recurrent bleeding occurred following 26.3% of interventions in seven patients at a mean interval of 22 days. The site of recurrent bleeding was new in 80% of cases. There was no significant difference in recurrent bleeding rate in early-onset (< 30 d; n = 22) versus late-onset PPAH (> 30 d; n = 6; P > .05). No ischemic hepatic or bowel complications were identified. The 30-day mortality rate was 7.1% (n = 2) and was significantly higher in patients with initial PPAH at ≥ 39 days (n = 5; P = .007). CONCLUSIONS: Covered stents and coil embolization are effective for managing PPAH and maintaining distal organ perfusion to minimize morbidity and mortality. Recurrent bleeding is common and most often occurs from new sites of vascular injury rather than previously treated ones.

Percutaneous ablation versus surgical ablation and resection of liver tumors: medicare volume and physician reimbursement trends from 2010 to 2018.

PURPOSE: The purpose of this study is to analyze trends in Medicare volume and physician reimbursement for percutaneous ablation, surgical ablation, and resection of liver tumors from 2010 to 2018. METHODS: Claims from the Medicare Part B PSPSMF for the years 2010 to 2018 were extracted using the CPT codes for percutaneous and surgical ablation of liver tumors and surgical liver resection. Total procedural volume and physician payment were analyzed by procedure and physician specialty. RESULTS: From 2010 to 2018, the volume of percutaneous ablation of liver tumors increased 94.3% from 1630 to 3168 procedures, and the volume of surgical ablations increased 86.2% from 593 to 1104 procedures. In contrast, there was a 16.8% decrease in liver resections from 10,807 to 8994 procedures. Physician reimbursement for percutaneous ablation decreased from $702.41 to $610.11 (- 13.1%). Conversely, reimbursement for resection increased from $849.18 to $1015.06 (19.5%). Reimbursement for surgical ablation also increased from $722.36 to $744.25 (3.0%). In 2018, physician reimbursement for resection and surgical ablation were 66% and 22% more than that for percutaneous ablation. CONCLUSION: An increasing number of patients with liver tumors were treated with percutaneous ablation from 2010 to 2018. Despite higher morbidity, a dwindling set of theoretical advantages over percutaneous ablation, and higher overall costs, the volume of surgical ablation also increased over this time period. The findings of this study suggest that a reevaluation of practice and referral patterns for surgical ablation of liver tumors is warranted in many institutions.

Spontaneous Regression of Advanced Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality. The tumor carries poor prognosis with curative therapeutic options limited to surgical resection, tumor ablation, and liver transplantation. Rarely, there is spontaneous regression of the tumor. We describe the case of a 74-year-old male with cirrhosis from non-alcoholic steatohepatitis who developed advanced HCC that was associated with tumor invasion of the portal vein and marked elevation of serum alfa-fetoprotein level. The patient received no cancer-specific therapy. However, 1 year after the initial diagnosis, he was noted to have complete regression of the tumor. In this report, we discuss possible mechanisms of spontaneous tumor regression and its therapeutic implications.

Novel therapy for non-cirrhotic hyperammonemia due to a spontaneous splenorenal shunt.

Spontaneous splenorenal shunts in the absence of cirrhosis have rarely been reported as a cause hyperammonemia with encephalopathy. Several closure techniques of such lesions have been described. Here we report a case of a patient with no history of liver disease who developed significant confusion. After an extensive workup, he was found to have hyperammonemia and encephalopathy due to formation of a spontaneous splenorenal shunt. There was no evidence of cirrhosis on biopsy or imaging and no portal hypertension when directly measured. The shunt was 18 mm and too large for embolization so the segment of the splenic vein between the portal vein and the shunt was occluded using an Amplatzer plug. Thus, the superior mesenteric flow was directed entirely to the liver. After interventional radiology closure of the shunt using this technique there was complete resolution of symptoms. The case represents the first report of a successful closure of splenorenal shunt via percutaneous embolization of the splenic vein with an amplatzer plug using a common femoral vein approach.