A rare case of paradoxical pulmonary embolism in spontaneous aortocaval fistula.

Aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysm (AAA), occurring in less than 1% of all AAAs. Paradoxical embolism can rarely be associated with ACF, pulmonary embolism may originate from dislodgment of thrombotic material from the AAA in the inferior vena cava (IVC) through the ACF. We report a case of a patient admitted to the emergency department with abdominal pain and shortness of breath who immediately underwent thoraco-abdominal CT. Imaging allowed a prompt pre-operative diagnosis of an ACF between an AAA and the IVC, also identifying CT signs of right heart overload and the presence of a paradoxical pulmonary embolism.

Splenosis of the abdomen and pelvis complicated by torsion of a splenic implant clinically mimicking an acute bowel ischemia.

We present a case of splenosis of the abdomen and pelvis complicated by torsion of a splenic implant in a young female patient clinically mimicking an acute bowel ischemia. Splenosis is a benign condition defined as heterotopic auto-transplantation of splenic tissue throughout different body areas. It may occur after rupture of the spleen, either traumatic or secondary to surgical procedures. Although the presence of heterotopic splenic tissue is often asymptomatic and an incidental finding, it may present with sudden abdominal pain and bleeding. CT and MRI play a critical role in the detection of splenosis-related complications, such as torsion of the vascular pedicle and infarction. Splenosis torsion is extremely rare and it is still a diagnostic dilemma; the complication of abdominal splenosis should be considered in the differential diagnosis in patients with previous splenectomy.

Three-dimensional surface imaging for detection of intra-fraction setup variations during radiotherapy of pelvic tumors.

PURPOSE: Surface-based image guided radiotherapy (IGRT) allows positioning and/or monitoring patients in 3 dimensions (3D), without the use of ionizing radiation. In this study, we report on intra-fraction motion measured by acquisition of multiple images of 3D body surfaces. MATERIALS AND METHODS: Twenty-nine patients treated for pelvic tumors were enrolled. Setup variations (SV) through three consecutive body surfaces acquired by the optical IGRT system Align-RT (Vision-RT, London, UK) were analyzed before, during and at the end of treatment delivery. Displacements along the main axes (X, Y and Z) from initial (I) to mid-treatment (MT) and final (F) acquisitions were recorded. Time and direction of SV were assessed. RESULTS: A total of 6272 images from 792 fractions of 29 patients were available. The main source of misalignment was between I and MT acquisition (p < 0.001). The dominant SV direction was the vertical one (Z axis), with mean SV of -1.20 ± 0.06 mm and -1.55 ± 0.06 mm for I-MT and I-F acquisitions, respectively. The Y mean components of SV were, respectively, -0.95 ± 0.10 mm and -1.0 ± 0.10 for I-MT and I-F acquisitions, while the X deviations were 0.07 ± 0.08 mm for I-MT and 0.26 ± 0.08 mm I-F. CONCLUSION: Three-D surface imaging for patient setup monitoring highlighted remarkable mobility of patients during RT session, especially in the anterior-posterior direction (Z axis). The largest magnitude in patient movements occurred during the first part of delivery. These findings suggest that the initial setup control cannot not to be sufficient to guarantee treatment reproducibility, especially for long-lasting RT treatments.

Transarterial chemoembolization with drug-eluting beads is effective for the maintenance of the Milan-in status in patients with a small hepatocellular carcinoma.

Transarterial chemoembolization (TACE) is the standard of care for the treatment of patients with an intermediate (Barcelona Clinic Liver Cancer [BCLC] B) hepatocellular carcinoma and to bridge patients with an early cancer to liver transplantation (LT). We explored the efficacy of TACE with drug-eluting beads (DEB) in BCLC A patients. Included are all BCLC A patients unsuitable for resection or locoregional ablation who underwent a DEB TACE between 2006 and 2012. Treatment was carried out "a la demande" until complete tumor devascularization or progression beyond Milan criteria. In patients with a complete response (CR), a contrast computed tomography (CT) scan was repeated at 3-month intervals during the first 2 years and then every 6 months alternating with abdominal ultrasound in the subsequent 3 years. Fifty-five patients had 79 tumor nodules ranging 7 to 50 mm; 32 (58%) achieved a CR that was maintained up to 4 and 7 months in 21 (38%) and 17 (31%) patients, respectively. The 24- and 36-month tumor-free survivals were 21% and 9%, respectively. The overall cumulative progression beyond Milan criteria at 3, 6, 12, and 24 months was 2%, 5%, 30%, and 54%. LT eligibility was maintained for a median of 19 months (range, 2-63 months). CR to first TACE was the strongest independent predictor of Milan-in maintenance. In conclusion, DEB TACE may effectively bridge patients with an early cancer to LT, and a CR to the first procedure may guide patient prioritization during the waiting list.

Drug delivery embolization systems: a physician's perspective.

INTRODUCTION: The number of patients suffering from primary and secondary liver tumoral diseases is on the increase worldwide. The development of new technologies and drugs requires an increasingly multidisciplinary approach in the management of these diseases. Therapies should be based on scientifically supported guidelines and at the same time should be designed to suit the individual patient. In this decision-making process, an understanding of the advantages and disadvantages of every treatment is very important. The efficacy of transarterial chemoembolization (TACE) in improving survival and its role in the management of hepatocellular carcinoma (HCC) have been demonstrated in several clinical trials. The introduction of drug-eluting beads seems to have overcome some of the limitations of conventional TACE. AREAS COVERED: This review provides an overview of the spread of primary and secondary liver cancers, then it explains the basis for the use of conventional TACE and its potential benefits and, finally, outlines its clinical application and possible future uses. EXPERT OPINION: The management of the treatment of focal liver lesions is a difficult process, which must involve various specialists such as the interventional radiologist. The use of drug-eluting microspheres seems to improve the results of TACE both in HCC and in colorectal liver metastases.

Transarterial chemoembolization with epirubicin-eluting beads versus transarterial embolization before liver transplantation for hepatocellular carcinoma.

PURPOSE: To retrospectively compare radiologic tumor response and degree of necrosis in explanted livers after chemoembolization with epirubicin-loaded DC Bead versus bland embolization in patients on a transplant waiting list. MATERIALS AND METHODS: From 2003 to 2007, 49 patients with hepatocellular carcinoma (HCC) underwent transplantation at a single center. Sixteen patients were treated with bland embolization (n = 8) with 100-300-microm Embosphere particles or chemoembolization with epirubicin-loaded 100-300-microm DC Bead particles (n = 8) every other month until complete tumor devascularization. Computed tomography was performed every 3 months until recurrence. Explanted livers were analyzed to evaluate the degree of necrosis in the nodules. After orthotopic liver transplantation (OLT), patients were followed up for survival and disease status. RESULTS: The groups were comparable for baseline characteristics. Most patients had Child-Pugh class A disease. Solitary HCC was found in 75% of patients. Mean target lesion size was 32 mm +/- 15.4. Chemoembolization with drug-eluting beads achieved complete necrosis in 77% of lesions whereas bland embolization achieved complete necrosis in 27.2% of lesions. There was a significant difference between bland embolization and chemoembolization with DC Bead with regard to histologic necrosis (P = .043). No significant treatment-related complications were observed for either group. Fifteen patients are alive with no tumor recurrence. CONCLUSIONS: Chemoembolization with drug-eluting beads before OLT achieved higher rates of complete histologic response than bland embolization, with no serious adverse events observed. Because of the retrospective data analyses and small sample size, further studies are warranted to confirm these promising results.

Transarterial chemoembolization for hepatocellular carcinoma with drug-eluting microspheres: preliminary results from an Italian multicentre study.

The purpose of this article is to present the early results of a multicentre trial using HepaSphere microspheres loaded with chemotherapeutic agents for transarterial chemoembolization (TACE) in patients with unresectable hepatocellular carcinoma. From December 2005 to March 2007, 50 patients (36 male and 14 female, mean age 68.4 years) were treated by selective TACE using HepaSphere microspheres loaded with doxorubicin or epirubicin. The diameter of the treated lesions ranged from 20 to 100 mm (mean 42.5; maximum of 4 tumor nodules). Tumor response was evaluated by computed axial tomography according to the World Health Organization criteria as modified by the European Association for the Study of Liver Diseases. All of the procedures were technically successful, and there were no major complications. At 1-month follow-up, complete tumor response was observed in 24 of 50 (48%), partial response in 18 of 50 (36%), and stable disease in 8 of 50 (16%) patients, and there were no cases of disease progression. At 6-month follow-up (31 of 50 patients), complete tumor response was obtained in 16 of 31 (51.6%), partial response in 8 of 31 (25.8%), and progressive disease in 7 of 31 (22.6%) patients. Within the initial 9-month follow-up, TACE with HepaSphere was successfully repeated twice in 3 patients, whereas 3 patients underwent the procedure 3 times. Our initial multicentre experience demonstrates that TACE using HepaSphere is feasible, is well tolerated, has a low complication rate, and is associated with promising tumor response. When complete tumor response in not achieved, additional treatments can be performed without difficulties. Longer follow-up on larger series is mandatory to confirm these preliminary results.