Vascular Interventions in Oncology.

Vascular interventions are an important and established tool in the management of the oncology patient. The goal of these procedures may be curative, palliative or adjunctive in nature. Some of the common vascular interventions used in oncology include transarterial embolisation or chemoembolisation, selective internal radiation therapy, chemosaturation, venous access lines, superior vena cava stenting and portal vein embolisation. We provide an overview of the principles, technology and approach of vascular techniques for tumour therapy in both the arterial and venous systems. Arterial interventions are currently mainly used in the management of hepatocellular carcinoma. Transarterial embolisation, chemoembolisation and selective internal radiation therapy deliver targeted catheter-delivered treatments with the aim of reducing tumour burden, controlling tumour growth or increasing survival in patients not eligible for transplantation. Chemosaturation is a regional chemotherapy technique that delivers high doses of chemotherapy directly to the liver via the hepatic artery, while reducing the risks of systemic effects. Venous interventions are more adjunctive in nature. Venous access lines are used to provide a means of delivering chemotherapy and other medications directly into the bloodstream. Superior vena cava stenting is a palliative procedure that is used to relieve symptoms of superior vena cava obstruction. Portal vein embolisation is a procedure that allows hypertrophy of a healthy portion of the liver in preparation for liver resection. Interventional radiology-led vascular interventions play an essential part of cancer management. These procedures are minimally invasive and provide a safe and effective adjunct to traditional cancer treatment methods. Appropriate work-up and discussion of each patient-specific problem in a multidisciplinary setting with interventional radiology is essential to provide optimum patient-centred care.

Weeping sponge kidney: an unusual phenomenon that should be considered in cases of severe renal haemorrhage.

AIM: To describe the clinical presentation, imaging evaluation, endovascular management, and outcomes of multifocal renal capsular haemorrhage, "weeping sponge kidney", and to identify associated risk factors and the pathophysiological mechanism behind this condition. MATERIALS AND METHODS: This is a case series in which clinical information for each of the cases was collected retrospectively from electronic patient notes as well as the radiology information and picture archiving and communication systems. RESULTS: Four consecutive cases were included in the series. All of the cases were treated successfully with embolisation. Three of the four patients had chronic renal failure with renal atrophy, which are patient factors that appear to be associated with multifocal renal capsular haemorrhage. Based on the procedural findings and the published literature, a pathophysiological mechanism is described to explain this condition and the relevance of the collateral arterial supply to the kidney in such cases is discussed. CONCLUSION: Small subcapsular haematomas are usually self-limiting but in patients with renal failure, there may be an increased risk of developing a weeping sponge kidney, which can be life-threatening. The endovascular treatment for multifocal haemorrhage differs from that for a single bleeding point, especially if preservation of renal function is not a priority.

Impact of site of occlusion in proximal splenic artery embolisation for blunt splenic trauma.

BACKGROUND: Proximal splenic artery embolisation (PSAE) can be performed in stable patients with Association for the Surgery of Trauma (AAST) grade III-V splenic injury. PSAE reduces splenic perfusion but maintains viability of the spleen and pancreas via the collateral circulation. The hypothesized ideal location is between the dorsal pancreatic artery (DPA) and great pancreatic artery (GPA). This study compares the outcomes resulting from PSAE embolisation in different locations along the splenic artery. MATERIALS AND METHODS: Retrospective review was performed of PSAE for blunt splenic trauma (2015-2020). Embolisation locations were divided into: Type I, proximal to DPA; Type II, DPA-GPA; Type III, distal to GPA. Fifty-eight patients underwent 59 PSAE: Type I (7); Type II (27); Type III (25). Data was collected on technical and clinical success, post-embolisation pancreatitis and splenic perfusion. Statistical significance was assessed using a chi-squared test. RESULTS: Technical success was achieved in 100% of cases. Clinical success was 100% for Type I/II embolisation and 88% for Type III: one patient underwent reintervention and two had splenectomies for ongoing instability. Clinical success was significantly higher in Type II embolisation compared to Type III (p = 0.02). No episodes of pancreatitis occurred post-embolisation. Where post-procedural imaging was obtained, splenic perfusion remained 100% in Type I and II embolisation and 94% in Type III. Splenic perfusion was significantly higher in the theorized ideal Type II group compared to Type I and III combined (p = 0.01). CONCLUSION: The results support the proposed optimal embolisation location as being between the DPA and GPA.

The role of interventional radiology in obstetric hemorrhage.

Obstetric hemorrhage remains a major cause of maternal morbidity and mortality worldwide. Traditionally, in cases of obstetric hemorrhage refractory to conservative treatment, obstetricians have resorted to major surgery with the associated risks of general anesthesia, laparotomy, and, in the case of hysterectomy, loss of fertility. Over the past two decades, the role of pelvic arterial embolization has evolved from a novel treatment option to playing a key role in the management of obstetric hemorrhage. To date, interventional radiology offers a minimally invasive, fertility-preserving alternative to conventional surgical treatment. We review current literature regarding the role of interventional radiology in postpartum hemorrhage, abnormal placentation, abortion, and cervical ectopic pregnancy. We discuss techniques, success rates, and complications.

High resolution imaging of the distribution and permeability of methyl viologen dication in bovine articular cartilage using scanning electrochemical microscopy.

Scanning electrochemical microscopy (SECM) has been used in the induced transfer (SECMIT) mode to image the permeability of a probe cation, methyl viologen (MV(2+)), in samples of articular cartilage. An ultramicroelectrode (UME), scanned just above the surface of a sample, is used to amperometrically detect the probe solute. The resulting depletion of MV(2+) in solution induces the transfer of this cation from the sample into the solution for detection at the UME. The current provides quantitative information on local permeability, provided that the sample-UME distance is known. It is shown that the necessary topographical information can be obtained using the amperometric response for the oxidation of Ru(CN)(4-)(6), which does not permeate into the cartilage matrix. This procedure was validated by marking samples in situ, after electrochemical imaging, with subsequent examination by ex situ interferometry and optical microscopy. Wide variations in the permeability of MV(2+) have been detected by SECMIT. These observations represent the first demonstration of the inhomogeneous permeability of a cation in cartilage on a micrometre scale. The permeability maps show similar features to the proteoglycan distribution, identified by toluidine blue staining, and it is likely that proteoglycans are the main determinant of MV(2+) permeability in articular cartilage.

Scanning electrochemical microscopy as a local probe of oxygen permeability in cartilage.

The use of scanning electrochemical microscopy, a high-resolution chemical imaging technique, to probe the distribution and mobility of solutes in articular cartilage is described. In this application, a mobile ultramicroelectrode is positioned close ( approximately 1 microm) to the cartilage sample surface, which has been equilibrated in a bathing solution containing the solute of interest. The solute is electrolyzed at a diffusion-limited rate, and the current response measured as the ultramicroelectrode is scanned across the sample surface. The topography of the samples was determined using Ru(CN)(6)(4-), a solute to which the cartilage matrix was impermeable. This revealed a number of pit-like depressions corresponding to the distribution of chondrocytes, which were also observed by atomic force and light microscopy. Subsequent imaging of the same area of the cartilage sample for the diffusion-limited reduction of oxygen indicated enhanced, but heterogeneous, permeability of oxygen across the cartilage surface. In particular, areas of high permeability were observed in the cellular and pericellular regions. This is the first time that inhomogeneities in the permeability of cartilage toward simple solutes, such as oxygen, have been observed on a micrometer scale.

A European version of the Appropriateness Evaluation Protocol. Goals and presentation. The BIOMED I Group on Appropriateness of Hospital Use.

This paper describes the development and testing of a European version of the Appropriateness Evaluation Protocol (AEP). It stemmed from the original U.S. version and the multiple adaptations and modifications made previously and separately by researchers in European countries. The group was particularly concerned with developing a common list of reasons for inappropriate admissions and days of stay, since the principal goal was to enable an understanding of inappropriate hospital use and potential solutions within local health and social care systems. Developing a common EU-AEP included several steps. First, each national instrument was translated from the national language to English. These back translations were compared with each other and with the US-AEP. A working group analyzed the content of the lists of reasons published in the literature and proposed a novel conceptual approach. On the basis of workshop discussions, a draft of a common European version was circulated to each participant for agreement. In the EU-AEP, the clinical criteria for the appropriateness of admission include 10 related to patient condition and five to clinical services. The criteria for the appropriateness of days of care include 10 covering medical services, six for life support/nursing services, and eight related to patient condition. The proposed core list of reasons of inappropriateness distinguish clearly between two concepts: a) the level of care required by the patient; and b) the reason why this level of care was not used. The first list would thus refer to the nature of resources and facilities required, while the second would focus more on the efficient organization of those resources. A validated European tool to assess inappropriate hospital admissions and hospital days of stay and their causes might be used to assess the need for resources for inpatient care as well as for outpatient care. Assessing the reasons for inadequacies might lead also to the examination of organizational questions. Finally, a common tool allows comparisons between countries concerning the frequency of inappropriate admissions and days of stay and their reasons in relation to the different organizations of health care across Europe.

Design and development of a utilization review program in Portugal.

This paper describes the work that has been under way in the Portuguese government hospital sector, with respect to the use of an adapted version of the Appropriateness Evaluation Protocol (AEP). Modifications to the original system were determined through a series of experiments at pilot hospitals and reliability and user profile studies were subsequently conducted using the modified criteria. Results were of great value in terms of the identification and quantification of problems. On average, approximately one in every four non-obstetric admissions and one in every 2 days of stay were deemed inappropriate and 75% of all inappropriate days were related to patients who were ready for discharge. It is expected that the use of the modified AEP will be extended and enhanced over the next few years. In this regard, advantage has already been taken of the implementation of an output-based funding system, combining retrospective statistical analysis of the hospitals' inpatient databases with targeted reviews of individual patients.

Relationship of serum levels of oncostatin M to AIDS-related and classic Kaposi's sarcoma.

Serum levels of circulating oncostatin-M (OM) were compared among cases of Kaposi's sarcoma associated with acquired immune deficiency syndrome (AIDS-KS) and multiple controls, including a homosexual man infected with human immunodeficiency virus type 1 (HIV-1), an HIV-1-uninfected homosexual man, and a heterosexual man; and among classic KS cases and heterosexual controls. Cases were selected from abstracts collected by a population-based cancer registry and from local AIDS clinics. Controls for the AIDS-KS cases were matched to the cases by age, sex, and race and were either friends of the cases or residents from the cases' neighborhoods; controls for the classic KS cases were similarly matched, but were obtained solely from neighborhood residents. Blood samples were obtained from participants, serum levels of OM were determined by enzyme-linked immunosorbent assay (ELISA), and CD4 cell counts were obtained by flow cytometry. Geometric mean levels of OM were compared among the risk groups adjusted for age and CD4 cell count. No differences in adjusted OM levels were found between AIDS-KS cases and HIV-1-infected homosexual controls (8.4 pg/ml vs. 10.2) or between classic KS cases and controls (13.3 pg/ml vs. 9.6); however the HIV-1-infected controls (both homosexual and heterosexual) matched to the AIDS-KS cases had higher levels than did the HIV-1-infected cases and controls. Among the HIV-1-infected groups, an inverse correlation between OM and CD4 cell count was observed and was statistically significant for the cases. Among all heterosexual controls (matched to either case group), serum OM was inversely related to age.(ABSTRACT TRUNCATED AT 250 WORDS)

The relevance of a staging laparotomy for Hodgkin's disease in India.

A retrospective analysis of 328 cases of Hodgkin's Disease (HD) subjected to a staging laparotomy at the Tata Memorial Hospital, Bombay, India, from 1974 to 1986 was undertaken to assess its relevance to our setup. Eighty percent of the patients were from clinical stages (CS) I and II, 38% with lymphocyte predominance (LP), and 41% with mixed cellularity (MC) histologies. Staging laparotomy was positive in 60% cases overall, including 50% from CS IA and IIA, 68% from CS IB and IIB, and 53% and 67%, respectively, from LP and MC histologies. Splenic involvement was seen in 54% cases. Operative complications were encountered in 2% of cases and deaths in two cases only. In view of the high propensity for abdominal spread, only selected CS IA and IIA cases would merit a staging laparotomy within which, nearly 50% cases with a negative yield could be offered radical segmental irradiation alone for cure. The majority of our patients would, however, require combination therapy.

Primary lymphoma of bone: experience of 39 cases at the Tata Memorial Hospital, India.

Primary lymphoma of bone (PLB) is an uncommon clinical entity and a rare presentation of non-Hodgkin's lymphoma. At the Tata Memorial Hospital, over a period of 10 years from 1976 to 1985, 39 cases with a diagnosis of PLB were seen. Twenty-seven cases completed the prescribed treatment and were evaluable for treatment response. Eight patients (21%) presented in clinical stage I (E), four patients (10%) in stage II (E), and 27 patients (69%) in stage IV (E). All of the evaluable patients except two were treated with combination chemotherapy, which consisted of cyclophosphamide, vincristine, and prednisolone in 18 patients, and seven patients received Adriamycin in addition. The majority of patients received six courses of chemotherapy extending over 8 to 12 months. External radiotherapy was given to all except one patient, who had surgery as local treatment. Five patients had generalised relapse, one of which had in addition a local relapse. Five were resistant to treatment. Overall and disease-free survival by Kaplan-Meier method at 60 months are 66% and 56%, respectively.

Continuous cyclophosphamide, doxorubicin, vincristine, and prednisolone. A new, innovative protocol for diffuse aggressive lymphomas.

One hundred eight patients with aggressive non-Hodgkin's lymphoma (high and intermediate grade) were treated with a new protocol: continuous cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP). They were evaluated for long-term survival and pretreatment characteristics predictive of response and survival. Continuous CHOP protocol consists of initial 8 weeks of intensive chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisolone, followed by local/cranial radiotherapy and maintenance therapy. Complete remission (CR) was achieved in 84 of 108 (78%) patients; seven (6%) had a moderate response and 17 (16%) had a poor response. A statistically significant difference in CR rate was found only in patients with different stages. Seventeen of 84 (20%) complete responders have had a relapse of the disease. The median survival has not been reached. Results show an actuarial disease-free survival (DFS) of 77% for the 84 patients who had a complete response. The overall survival for all patients was 53% at 5 years of follow-up. The difference in DFS at the end of 5 years between different stages, main histologic subgroups, and age groups was not statistically significant. The toxicity observed was acceptable. Thus continuous CHOP appears to be an effective protocol for the treatment of intermediate-grade and high-grade lymphomas.

Preosteoblast production 55 hours after a 12.5-day spaceflight on Cosmos 1887.

The influence of 12.5 days of spaceflight and a 55 h stressful recovery period (at 1 g) on fibroblastlike osteoblast precursor cells was assessed in the periodontal ligament (PDL) of rats that were 91 days old at launch. Nuclear morphometry was used as a marker for precursor cell differentiation in 3 microns sections cut in the midsagittal plane from the maxillary first molar. According to nuclear volume, cells were classified as preosteoblasts (C + D cells, greater than or equal to 120 microns 3) and less differentiated progenitor cells (A + A' cells, 40-79 microns 3). Compared with synchronous controls (simulated flight conditions), the 55 h postflight recovery period at 1 g resulted in a 40% decrease in the A + A' cell population, a 42% increase in the C + D cells, and a 39% increase in the number of PDL fibroblastlike cells near the bone surface. These results are consistent with a postflight osteogenic response in PDL. This recovery response occurred despite physiological stress in the flight animals that resulted in a highly significant (P less than or equal to 0.001) increase in adrenal weight. The data suggest that after spaceflight there is a strong and rapid recovery mechanism for osteoblast differentiation that is not suppressed by physiological stress.

Hodgkin's disease with bone marrow involvement.

Bone marrow involvement was seen in 11 percent of patients with Hodgkin's Disease which was determined from pre-treatment biopsy specimens using established histopathologic criteria. Analysis of 32 evaluable patients with marrow involvement showed male preponderance with a peak in fourth decade of life. Twenty four cases (75%) had B-symptoms and 15 (46%) presented within six months of onset of symptoms. On categorizing for clinical staging, 21 (65%) belonged to stage III and IV. Hepatomegaly (greater than or equal to 2 cms) was present in seven cases (21%) and splenomegaly in 13 cases (40%). Mixed cellularity and lymphocytic depletion histopathologic subtypes showed the highest frequency of involvement (21 cases; 65%). Out of 28 cases ESR was raised in 27 cases (96%). Eighteen cases (56%) showed elevated serum alkaline phosphatase levels. Serum copper levels were determined in 14 cases, out of which 12 (85%) showed elevated levels. These parameters along with anemia (hemoglobin of 12 g/dl or less) in 26 cases (81%), correlated well with the disease activity. Only four cases had leukopenia at presentation pointing to no hindrance for aggressive chemotherapy. All cases received minimum of six courses of standard combination chemotherapy with or without local radiotherapy. Sixteen cases (50%) relapsed subsequently and were managed accordingly. A five year follow-up revealed a minimal 31 percent overall survival, and 18 percent of patients were disease free and well since the time of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiotherapy of carcinoma of the buccal mucosa.

A retrospective study of 399 cases of buccal cancer, presenting to the Tata Memorial Hospital, Bombay, during January to December 1984 was undertaken to define the efficacy of various treatment modalities in different clinical stages. Analysis of treatment technique and response was carried out in 185 cases that completed adequate therapy. Sixty percent of patients with stage I and II disease (21/35) received radiation therapy alone as the primary modality of treatment. Patients (150) with stage III or IV disease received palliative irradiation (57 cases), radical surgery (54 cases), or a combination of both (39 cases). The 2-year disease-free survival (DFS) rates were 48% for radiotherapy and 46% for surgery in the early stages and 5% and 33%, respectively, for advanced stages. Radiotherapy with a modified technique is recommended for the early-stage cancers and preoperative irradiation with adjuvant chemotherapy or hyperthermia for the advanced stages.

Nuclear morphometric analysis of osteoblast precursor cells in periodontal ligament, SL-3 rats.

Five small (55 days old, 196 +/- 5 g) (mean +/- SE) and five large (83 days old, 382 +/- 4 g) Sprague-Dawley strain, specific pathogen-free rats were exposed to a 7-day spaceflight and 12-h postflight recovery period. As measured in 3-micron sections, periodontal ligament (PDL) fibroblastlike cells were classified according to nuclear size: A + A' (40-79), B (80-119), C (120-169), and D (greater than or equal to 170 microns 3). Since the histogenesis sequence is A----A'----C----D----osteoblast, the relative incidence of A + A' to C + D is an osteogenic index. No difference in A + A' or C + D cells in small rats may reflect partial recovery of preosteoblast formation (A----C) during the 12-h postflight period. Large flight rats demonstrated increased numbers of A + A', indicating an inhibition of preosteoblast formation (A----C). At least in the older group, a 7-day flight is adequate to reduce PDL osteogenic potential (inhibition in PDL osteoblast differentiation and/or specific attrition of C + D cells) that does not recover by 12-h postflight.