Microsecretory adenocarcinoma of the hard palate: A case report of a recently described entity.

We report a case of microsecretory adenocarcinoma of the hard palate. The patient is a 37-year-old woman with a 15 mm submucosal tumor, which was incidentally found by her primary care dentist, in her hard palate. Preoperative magnetic resonance imaging revealed a tumor exhibiting high signal on T2-weighted image, which was gradually enhanced on dynamic study. Histologically, the tumor border was ill-defined without fibrous capsule and adjoined minor salivary gland with permeative infiltration at the tumor periphery. The tumor comprised intercalated duct-like cells with polygonal narrow eosinophilic to clear cytoplasm and small, uniform oval nuclei. These cells formed small infiltrative microcysts, tubules and fascicular cords collecting pale basophilic secretions and small vacuoles setting in an abundant fibromyxoid stroma. The tumor cells were positive for CK AE1+AE3, S-100 protein, and p63, while are completely negative for p40, alpha-SMA, and calponin. The MEF2C-SS18 fusion was identified by reverse transcriptase-polymerase chain reaction followed by Sanger sequencing. The combination of characteristic histology, immunophenotype, and presence of MEF2C-SS18 fusion indicated the diagnosis of microsecretory adenocarcinoma of the hard palate, an entity described only recently. Post-operative course was uneventful and there was no evidence of disease at 4 months after surgery.

Shunt-preserving disconnection of the portal to systemic circulation in patients with hepatic encephalopathy.

Background Portosystemic shunt obliteration by surgical or interventional radiological techniques can be effective for patients with hepatic encephalopathy (HE) although this approach is often associated with accumulation of ascites and/or formation of esophageal varices. Purpose To evaluate the clinical efficacy and safety of shunt-preserving disconnection of the portosystemic circulation (SPDPS) in patients with HE. Material and Methods Nine patients with HE and a splenorenal shunt were treated by SPDPS: eight underwent selective coil embolization of the splenic vein and one underwent stent-graft closure of the shunt. The primary endpoint was change in HE severity based on the West-Haven criteria. The secondary endpoints were changes in serum ammonia levels, hepatic function, HE recurrence during the follow-up period, and post-treatment HE recurrence based on the West-Haven diagnostic criteria. Results The technical success rate was 100% with no severe complications. After the procedure, the mean portal blood pressure increased from 18 mmHg to 22 mmHg ( P = 0.02), the mean HE grades fell from 2.1 to 1.1 ( P < 0.01), and one month after the procedure, the mean serum ammonia level decreased from 177 µg/dL to 87 µg/dL ( P = 0.03) and the mean total Child-Pugh score from 8 to 7 ( P = 0.07). Conclusion SPDPS using selective coil embolization and stent-graft closure of the shunt can be an effective and safe treatment for patients with HE.

Percutaneous transhepatic portal embolization using foam ethanolamine oleate and carbon dioxide (CO2): a pilot study.

BACKGROUND: Percutaneous transhepatic portal embolization (PTPE) can induce atrophy of the embolized- and hypertrophy of the residual area. These effects are advantageous in patients scheduled for extended hepatectomy. PURPOSE: To evaluate the clinical safety and effectiveness of foam sclerotherapy with foam ethanolamine oleate (EO) and carbon dioxide (CO2) for PTPE before hepatectomy. MATERIAL AND METHODS: We performed sclerotherapy for PTPE in 15 patients with: hepatocellular carcinoma (HHC; n = 9), bile duct carcinoma (n = 5), or metastatic liver tumor from colon cancer (n = 1). The foam contained 5% EO iopamidol (EOI) and CO2 at a 1:2 ratio. We compared the percentage of the pre- and post-PTPE future liver remnant (FLR) volumes and calculated the percent FLR volume (%FLR) increase after PTPE. RESULTS: The amount of EOI used (range, 14-20 mL; median, 16.8 mL) was based on the volume of the target portal vein. Technical success was achieved in 14 of 15 patients (93%); the other patient presented with computed tomography evidence of recanalization 1 week after PTPE. The FLR volume before and after portal vein embolization was 599 ± 342 and 691 ± 318 cm(3), respectively (P < 0.01); the mean %FLR volume increase was 29.5%. There was no significant difference in the mean platelet count, total bilirubin, total aspartate aminotransferase, and total creatinine before and after PTPE. One patient suffered intra-abdominal bleeding that required transcatheter arterial embolization. No other patients developed major complications higher than grade 3. CONCLUSION: Sclerotherapy using foam EOI and CO2 is clinically safe and effective for PTPE before hepatectomy.

Pain control in patients with hepatocellular carcinoma treated by percutaneous radiofrequency ablation: comparison of the efficacy of one-shot and continuous intravenous fentanyl delivery.

BACKGROUND: Hepatic percutaneous radiofrequency ablation (RFA) is usually performed with the patient under deep intravenous (i.v.) sedation or general anesthesia. Nonetheless, many patients report pain during and/or after the procedure. PURPOSE: To perform a prospective study of pain control obtained by the i.v. one-shot delivery and the continuous i.v. infusion of fentanyl in patients with hepatocellular carcinoma (HCC) treated by RFA. MATERIAL AND METHODS: Between April 2007 and March 2010, 83 patients with 106 HCCs underwent percutaneous RFA. All HCCs were addressed by computed tomography (CT)-guided percutaneous RFA performed within 5 h of embolization of the tumor vessels with iodized oil and gelatin sponges. Standard anesthesia consisted of 10 mL of 1% lidocaine injected locally. For conscious sedation, group one patients (n = 41) were injected i.v. with 100 µg of fentanyl before and 100 µg of fentanyl 30 min after percutaneous RFA. In group two (n = 42) we delivered fentanyl by continuous i.v. infusion at 100 µg/h during RFA. Upon request, patients in both groups also received 5 mg of diazepam i.v. for pain during the RFA procedure. The severity of pain experienced by all patients was evaluated on a visual analogue scale (VAS) and complications elicited by the anesthesia regimens were recorded. We also assessed the effectiveness of the treatment on sequential follow-up CT and/or magnetic resonance imaging (MRI) at 3-month intervals. RESULTS: Percutaneous RFA was technically successful in all 83 patients. Two patients in group one (4.8%) and one patient in group two (2.4%) manifested residual enhancement 3 months post RFA. There was no significant difference in the local recurrence rate between the two groups. At 4.0 ± 1.8 for group one and 3.4 ± 1.9 for group two, the VAS score was not significantly different. Major fentanyl or diazepam toxicity was recorded in 11 patients (24.4%) in group one and two patients (4.8%) in group two; the difference was statistically significant (P < 0.01). CONCLUSION: The continuous infusion of fentanyl provided effective and safe analgesia in HCC patients undergoing percutaneous RFA.

Comparison of CT-guided percutaneous biopsy with and without registration of prior PET/CT images to diagnose mediastinal tumors.

PURPOSE: To compare computed tomography (CT)-guided percutaneous biopsy with and without registration of prior positron emission tomography (PET)/CT images in the diagnosis of mediastinal tumors. METHODS: We performed clinically indicated percutaneous biopsy in 106 patients with mediastinal tumors in the anterior (n = 61), posterior (n = 21), middle (n = 16), and superior mediastinum (n = 8). The final diagnosis was based on surgical outcomes, or imaging findings and the results of at least 6-month follow-up. The patients underwent CT-guided percutaneous biopsy with (group 1, n = 56) or without (group 2, n = 50) registration of prior PET/CT images obtained no more than 22 days earlier. The registered images were used to plan the procedure and help target the tumors. RESULTS: CT-guided percutaneous needle biopsy yielded adequate samples in 101 of 106 (95 %) patients (group 1, n = 53; group 2, n = 48); in 95 patients (94 %), the diagnosis was confirmed by specific histological typing (group 1, n = 51; group 2, n = 44). The diagnostic accuracy of CT-guided percutaneous biopsy with and without the registration of prior PET/CT images was not statistically different (group 1, 96 %; group 2, 93 %, p = 0.324). CONCLUSION: CT-guided percutaneous biopsy is an easy and safe procedure that can provide a precise diagnosis in the majority of mediastinal tumors. PET/CT-guided biopsy yielded no special diagnostic advantages.

Successful treatment of mesenteric varices by retrograde transvenous obliteration by the delivery of N-butyl-2-cyanoacrylate via an abdominal wall vein.

Bleeding from mesenteric varices associated with portal hypertension is occasionally life-threatening. A 53-year-old man who had undergone esophageal transection for esophageal varices and balloon-occluded retrograde transvenous obliteration for gastric varices presented with melena due to ruptured mesenteric varices. He was treated by injecting N-butyl-2-cyanoacrylate via an abdominal wall vein to obtain retrograde transvenous obliteration.

Simultaneous coil embolization and angioplasty using a self-expanding nitinol stent to treat pancreaticoduodenal artery aneurysms associated with celiac artery stenosis.

BACKGROUND: The degeneration of pancreaticoduodenal arcade vessels due to pancreaticoduodenal artery aneurysms is associated with celiac artery stenosis or occlusion. While technical advances have made it possible to treat pancreaticoduodenal arcade aneurysms (PDAA) and celiac artery stenosis by endovascular techniques, there is no consensus regarding their optimal treatment. PURPOSE: To treat pancreaticoduodenal arcade aneurysms (PDAA) by simultaneous coil embolization and celiac artery stenting, and propose indications for treating PDAA with celiac artery stenosis by this method. MATERIAL AND METHODS: We reviewed 11 patients who underwent transcatheter coil embolization (TCE) to treat PDAA. When the aneurysmal neck size was less than half of the short axis of the aneurysm we used packing only, when it was more than half of the short axis we undertook isolation. In the latter situation, when there was evidence of celiac artery stenosis, we performed celiac artery stenting using self-expandable stents. RESULTS: Ten of the 11 patients (91%) presented with celiac axis stenosis due to median arcuate ligament compression. Coil-packing of the aneurysmal sac only, thus preserving the native arterial circulation, was done in five patients, another five underwent isolation by embolization of vessels distal and proximal to the PDAA with simultaneous stenting of the stenotic celiac axis, and one patient was treated by isolation only. One patient developed acute pancreatitis. There were no other complications and all aneurysms were successfully excluded. In one patient the celiac stent thrombosed after stopping the antiplatelet regimen. CONCLUSION: TCE can be effective in patients with PDAA. In the presence of celiac artery stenosis, we recommend isolation of the aneurysms with simultaneous stenting of the stenotic celiac trunk using self-expandable stents.