Effect of Magnetic Resonance Imaging on Acute Surgical Treatment of Pregnant Patients: A Single Institution Study.

BACKGROUND: Abdominal pathology in pregnant patients is a frequent challenge for emergency department physicians. Ultrasound is the imaging modality of choice but is inconclusive in approximately one-third of cases. Magnetic resonance imaging (MRI) is becoming increasingly available, even in acute settings. Multiple studies have defined the sensitivity and specificity of MRI in this population. OBJECTIVES: To evaluate the use of MRI findings in pregnant patients presenting with acute abdominal complaints to the emergency department. METHODS: This retrospective cohort study was conducted at a single institution. Data were collected on pregnant patients who underwent an MRI for acute abdominal complaints between 2010 and 2019 at a university center. Patient demographics, diagnosis at admission, ultrasound and MRI findings, and discharge diagnosis were recorded and evaluated. RESULTS: In total, 203 pregnant patients underwent an MRI for acute abdominal complaints during the study period. MRI was found without pathology in 138 cases (68%). In 65 cases (32%), the MRI showed findings that could explain the patient's clinical presentation. Patients presenting with long-standing abdominal pain (> 24 hours), fever, leukocytosis, or elevated C-reactive protein values were at a significantly increased risk of having an acute pathology. In 46 patients (22.6%), MRI findings changed the primary diagnosis and management while in 45 patients (22.1%) MRI findings improved characterization of the suspected pathology. CONCLUSIONS: MRI is helpful when clinical and sonographic findings are inconclusive, leading to changes in patient management in more than one-fifth of patients.

Pneumatosis Cystoides Coli Presenting as Acute Abdomen in a Patient with Complicated Behcet's Disease: A Case Report.

BACKGROUND Behcet's disease (BD) is defined as vasculitis involving arteries and veins of any size and affecting almost any organ system. Abdominal manifestations of BD are diverse and nonspecific. Mucosal ulcerations can be seen in the gastrointestinal tract. Extensive ulcerations, especially ileocecal lesions, can lead to perforation, strictures, fistulas, and abscesses. Pneumatosis cystoides intestinale is a rare benign condition characterized by multiple submucosal or subserosal, gas-filled cysts in the gastrointestinal tract wall. Pneumatosis cystoides coli (PCC) affects the colon, can present with a wide range of manifestations, and can mimic many different systemic diseases. We describe a case of PCC in a patient with Behcet's disease who presented to the Emergency Department with a clinical suspicion of acute abdomen. CASE REPORT A 40-year-old man with complicated Behcet's disease, treated with high-dose steroids, presented with acute abdomen and CT scan findings highly suggestive of intestinal obstruction due to ileocolic intussusception. He underwent laparoscopic right hemicolectomy. Pathology demonstrated PCC disease. CONCLUSIONS Pneumatosis cystoides coli can present with a broad range of symptoms and can be secondary to many systemic and autoimmune diseases. With radiological evidence and a high level of suspicion, unnecessary surgery can be prevented.

Consistency of Thyroid Imaging Reporting and Data System Reporting in Community-Based Imaging Centers Versus a Large Tertiary Hospital.

OBJECTIVE: In our country, thyroid nodules are sonographically evaluated in health maintenance organization (HMO) imaging centers, and patients are referred to tertiary hospitals for ultrasound-guided fine-needle aspiration (FNA) biopsy when indicated. We evaluated the concordance in Thyroid Imaging Reporting and Data System (TI-RADS) classification reporting between these sites. METHODS: We conducted a retrospective cohort study reviewing the sonographic features of thyroid nodules evaluated both at the HMO and a large tertiary center between January 2018 and December 2019. The primary outcome was concordance between the TI-RADS classification at both sites. Additional endpoints included correlation of TI-RADS to the Bethesda category following FNA and correlation of TI-RADS with malignancy on final pathology at each site. RESULTS: The records of 336 patients with 370 nodules were reviewed. The level of concordance was poor (19.8%), with 277 (74.8%) nodules demonstrating higher TI-RADS and 20 (5.4%) lower TI-RADS at the HMO compared to the hospital (P < .001; weighted κ = 0.120). FNA results were available for 236 (63.8%) nodules. The Bethesda category strongly correlated with the hospital TI-RADS (P < .001), yet not with HMO TI-RADS (P = .123). In the surgically removed 57 nodules, a strong correlation was identified between the malignancy on final pathology and TI-RADS documented at the hospital (P < .001), yet not at the HMO (P = .259). CONCLUSIONS: There is poor agreement between TI-RADS classification on ultrasound performed in the HMO compared to a tertiary hospital. The hospital's TI-RADS strongly correlated with the Bethesda category and the final risk of malignancy, unlike the HMO.

CT severity indices derived from low monoenergetic images at dual-energy CT may improve prediction of outcome in acute pancreatitis.

OBJECTIVES: To determine whether imaging features and severity indices using low monoenergetic DECT images improve diagnostic conspicuity and outcome prediction in acute pancreatitis compared to conventional images. METHODS: A retrospective study of patients with clinical and radiographic signs of acute pancreatitis who underwent 50 contrast-enhanced CT exams conducted on a single-source DECT was performed. Representative conventional and 50 keV-monoenergetic images were randomized and presented to four abdominal radiologists to determine preferred imaging for detecting fat stranding and parenchymal inflammation. Contrast and signal-to-noise ratios were constructed for necrotic, hypoattenuated, inflamed, and healthy parenchyma. These parameters and the CT severity index (CTSI) were compared between conventional and low monoenergetic images using paired t tests and correlated to clinical outcome. RESULTS: Although preference for conventional images was noted for subtle peri-pancreatic fat stranding (169/200 (85%) reads), there was clear preference for low monoenergetic images among all readers for pancreatic inflammation evaluation (188/200 (94%) reads). Moreover, identification of small, hypoattenuating inflammatory foci on monoenergetic images alone in 13/50 (26%) cases resulted in upstaged CTSI from mild to moderate in 7/50 (14%), associated with longer hospitalization (16 ± 17 days vs. 5 ± 2 days; p < 0.05), ICU admission, and drainage. Quantitatively, a twofold difference between normal and inflamed parenchyma attenuation was identified for monoenergetic (44.8 ± 27.6) vs. conventional (25.1 ± 14.7) images (p < 0.05). Significant increases were seen in the monoenergetic SNR and CNR compared to the conventional images (p < 0.05). CONCLUSIONS: DECT low monoenergetic images afford better tissue assessment and demarcation of inflamed pancreatic parenchyma. Additionally, they provide improved characterization of the extent parenchymal necrosis, enabling better classification that may better predict severe clinical outcomes. KEY POINTS: • DECT low monoenergetic images afford better tissue assessment and demarcation of inflamed pancreatic parenchyma and provide improved characterization of the extent parenchymal necrosis. • Qualitatively, low monoenergetic images were preferred over conventional DECT images for the evaluation of pancreatic inflammation; and quantitatively, there is a twofold difference between normal and inflamed parenchyma attenuation, SNR, and CNR between monoenergetic vs. conventional images. • Monoenergetic imaging identified additional small, hypoattenuating inflammatory foci in 26% resulting in an upstaged CT severity index in 14% associated with longer hospitalization, ICU admission, and drainage, thereby enabling better classification and better prediction of severe clinical outcomes.

US-guided laser treatment of parathyroid adenomas.

Objective: To determine the clinical efficacy of laser ablation for the tredatment of primary hyperparathyroidism (pHPT).Materials and methods: Twelve patients with pHPT were treated with laser ablation. Energy was administered by means of 1.5 m optical fibers percutaneously placed into the target via 21 G needles. A laser ablation unit (EchoLaser X4, Esaote) applied 3 W power for 400-600 s/fiber/insertion to a total 3600-9000 Joules of energy. Patient serum parathyroid hormone (PTH) and calcium levels were checked at baseline and thereafter every 6 months. Patients were followed-up for 2 years with serologic and contrast-enhanced ultrasound. Therapeutic success was defined as normal PTH and calcium levels together with disappearance of nodule-related symptoms.Results: All procedures were performed in single session. Immediately following ablation, contrast enhanced ultrasound confirmed that all but one target had become avascular (technical success rate 11/12; 92%), remaining avascular at all follow-up ultrasound examinations, thereafter. The mean volume of parathyroid nodules decreased from 0.54 cc to 0.36 cc (72.0%). Serum PTH and calcium levels were significantly lower at 1, 12 and 24 m compared to baseline (p < 0.01). By 6 m, PTH and calcium returned to normal and were stable until 24 m in all successfully treated patients. All cases of hyperparathyroid-related symptoms resolved by 6 m (ostealgia [n = 5], repeated renal colic [n = 5], vomiting [n = 3]). Only one patient (8%) reported transient dysphonia as a minor complication.Conclusion: Laser ablation of enlarged, symptomatic parathyroid glands is safe and well-tolerated and can produce long-term, sustained reduction of serum PTH and calcium levels.

VHL-Related Neuroendocrine Neoplasms And Beyond: An Israeli Specialized Center Real-Life Report.

OBJECTIVE: Von Hippel-Lindau (VHL) syndrome is a rare and complex disease. In 1996, we described a 3 generation VHL 2A kindred with 11 mutation carriers. We aim to share our experience regarding the long-term follow-up of this family and the management of all our other VHL patients focusing on frequently encountered neuroendocrine neoplasms: pheochromocytoma/paraganglioma and pancreatic neuroendocrine neoplasms (PNEN). METHODS: All VHL patients in follow-up at our tertiary center from 1980 to 2019 were identified. Clinical, laboratory, imaging, and therapeutic characteristics were retrospectively analyzed. RESULTS: We identified 32 VHL patients in 16 different families, 7/16 were classified as VHL 2 subtype. In the previously described family, the 4 initially asymptomatic carriers developed a neuroendocrine tumor; 7 new children were born, 3 of them being mutation carriers; 2 patients died, 1 due to metastatic PNEN-related liver failure. Pheochromocytoma was frequent (22/32), bilateral (13/22;59%), often diagnosed in early childhood when active screening was timely performed, associated with paraganglioma in 5/22, rarely malignant (1/22), and recurred after surgery in some cases after more than 20 years. PNEN occurred in 8/32 patients (25%), and was metastatic in 3 patients. Surgery and palliative therapy allowed relatively satisfactory outcomes. Severe disabling morbidities due to central-nervous system and ophthalmologic hemangiomas, and other rare tumors as chondrosarcoma in 2 patients and polycythemia in 1 patient were observed. CONCLUSION: A multidisciplinary approach and long-term follow-up is mandatory in VHL patients to manage the multiple debilitating morbidities and delay mortality in these complex patients.

Bleeding Risk Assessment and the Role of Primary Hemostasis Screening in Patients Undergoing Kidney Biopsy.

BACKGROUND: Risk factors for bleeding complications after percutaneous kidney biopsy (PKB) and the role of primary hemostasis screening are not well established. OBJECTIVES: To determine the role of primary hemostasis screening and complication outcomes among individuals who underwent PKB. METHODS: We reviewed data of 456 patients who underwent PKB from 2010 to 2016 in a large university hospital. In 2015, bleeding time (BT) testing was replaced by light transmission aggregometry (LTA) as a pre-PKB screening test. RESULTS: Of the 370 patients who underwent pre-PKB hemostasis screening by BT testing, prolonged BT was observed in 42 (11.3%). Of the 86 who underwent LTA, an abnormal response was observed in 14 (16.3%). Overall, 155 (34.0%) patients experienced bleeding: 145 (31.8%) had minor events (hemoglobin fall of 1-2 g/dl, macroscopic hematuria, perinephric hematoma without the need for transfusion or intervention) and 17 (3.7%) had major events (hemoglobin fall > 2 g/dl, blood transfusion or further intervention). Abnormal LTA response did not correlate with bleeding (P = 0.80). In multivariate analysis, only prolonged BT (P = 0.0001) and larger needle size (P = 0.005) were identified as independent predictors of bleeding. CONCLUSIONS: Bleeding complications following PKB were common and mostly minor, and the risk of major bleeding was low. Larger needle size and prolonged BT were associated with a higher bleeding risk. Due to the relatively low risk of major bleeding and lack of benefit of prophylactic intervention, the use of pre-PKB hemostasis screening remains unestablished.

Changes in abdominal wall thickness during laparoscopy: implications for the use of magnetic assisted surgery.

Introduction: Recently, magnetic solutions have been proposed to minimize surgical invasiveness. These are comprised of deployable instruments containing magnets which are inserted into the abdominal cavity through a single access point. The manipulation of the internal elements occurs via magnets held on the external surface of the abdominal wall. This technology relies on the magnetic force between the magnets, which is inversely related to the abdominal wall thickness (AWT). The aim of this study was to establish the expected change in AWT from before and after initiation of pneumoperitoneum. Material and methods: Patients scheduled for laparoscopic procedures were assessed by ultrasound for AWT immediately before and during laparoscopy. Change of AWT during laparoscopy was calculated. Statistical analysis was performed using Student's t-test. Results: Thirty-two patients undergoing various laparoscopic procedures were included. Twenty patients were male (62.5%) and ten were morbidly obese (31%). Mean age was 51 years (range 18-76) and average BMI was 28.1 kg/m2 (range 19.0-41.0). AWT decreased on average by 15.6% once pneumoperitoneum was initiated in both obese and non-obese patients (p = .01). Conclusion: Our data suggest that following preoperative assessment of AWT with abdominal wall ultrasound, more patients than expected might be candidates for the use of trans-abdominal magnetic devices.

Serum Thymidine Kinase 1 Activity Following Nephrectomy for Renal Cell Carcinoma and Radiofrequency Ablation of Metastases to Lung and Liver.

BACKGROUND/AIM: Thymidine kinase 1 (TK1) is involved in DNA synthesis and is considered a reliable and sensitive marker of cell proliferation. The aim of this study was to investigate the prognostic value of measurements of serum TK1 activity following tumor ablation. PATIENTS AND METHODS: This study was performed on 32 patients with renal cell carcinoma (RCC) who had undergone nephrectomy and 35 patients with cancer of different histology with metastases to the liver (n=28) and lung (n=7) treated with radiofrequency ablation (RFA). The TK1 activity was measured with DiviTum (Biovica) immunoassay. RESULTS: In patients with RCC with no evidence of disease during their observation, a significant decrease of the TK1 activity was observed on the day following nephrectomy (p<0.0001). The mean calculated half-life ±SEM was 10.8±1.2 h. Taking into account the short half-life, measurements of TK1 were performed 24 h after nephrectomy or RFA of metastases. It was found that elevated TK1 activity (>60 Du/l) on the day after nephrectomy independently predicted poor recurrence-free survival (hazard ratio=5.0, p=0.040), after adjustment for T-stage, age and pretreatment TK1. Patients scheduled for RFA averaged 1.4 lesions and an average lesion diameter of 2.2 cm. Multivariate Cox's regression model demonstrated the significant association of any increase of TK1 activity or decrease not reaching ≤60 Du/l on the day after ablation with poor progression-free survival (hazard ratio=4.6, p=0.001), after adjustment for the type of primary tumor, the number and size of metastases. CONCLUSION: The half-life for serum TK1 activity is 10.8±1.2 h. The measurements of TK1 activity following nephrectomy or RFA of metastases could be an important tool in prognostic evaluation.

Baseline abdominal lipid partitioning is associated with the metabolic response to bariatric surgery.

BACKGROUND: The purpose of this study was to compare the effects of two bariatric procedures on abdominal lipid partitioning and metabolic response. METHODS: Fifty-one patients (RYGB 31(11 M/20 F); (SG) 20(8 M/12 F)) who met the criteria of metabolic syndrome before the operation were followed following Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Visceral and subcutaneous abdominal fat depots were assessed by CT before, 6 months, and 12 months following the operation. RESULTS: Patients undergoing both procedures did not differ in baseline body mass index (BMI) (42.84 ± 4.65 vs. 41.70 ± 4.68 kg/m(2)) or abdominal lipid depots. BMI at 12 months post-op was similar (29.44 ± 3.35 vs 30.86 ± 4.31 kg/m(2) for RYGB and SG, respectively). Both procedures led to a significant reduction in visceral and subcutaneous fat at 6 months (p < 0.001 for both). The visceral-to-subcutaneous fat ratio was comparable at 6 months vs. baseline yet was lower at 12 months vs. baseline for both procedures (p < 0.01). In patients who lost the diagnosis of metabolic syndrome, baseline visceral/subcutaneous fat was the only predictor of recovery (p < 0.005). No difference was detected between procedures in dynamics of abdominal fat depots or remission of cardiovascular risk factors. CONCLUSIONS: RYGB and SG induce a similar effect on abdominal fat mobilization. The metabolic effects in individual patients are mostly determined by their baseline abdominal lipid partitioning.

Computed tomography of Lipiodol-loaded biodegradable pasty polymer for implant visualization.

Targeted delivery of drug-loaded implants for regional drug therapy has become an important approach to therapy. Simple and reproducible imaging methodologies to evaluate the implant noninvasively are needed. The goal of this work was to noninvasively evaluate the visibility, shape and degradation of a biodegradable implant containing Lipiodol (an X-ray contrast medium) by computed tomography (CT). For in vitro evaluation, Lipiodol was incorporated in poly(sebacic-co-ricinoleic acid) [P(SA:RA)], a biodegradable injectable pasty polymer, and CT visibility was assessed. For ex vivo evaluation, bovine liver was injected with the polymer-loaded Lipiodol; for in vivo evaluation rats were injected subcutaneously with Lipiodol in polymer and CT was performed. We show that polymer diameter at CT correlates with implant weight and pathological measurements. Polymer formulation containing 5% Lipiodol was visible on CT in vitro. Ex vivo tests showed a round polymer deposit at the injection site compared with free dispersion of Lipiodol alone. Correlation between implant size at CT scan and surgery at 48 h was R(2) = 0.78. Average CT diameter at 9 days was 14.2 ± 2.8 mm in rats injected with Lipiodol in the polymer formulation, as compared with 7.3 ± 1.1 mm in controls. After 9 days, the implant degraded into several zones containing inflammatory cells seen on CT as areas with increased heterogeneity. In conclusion, Lipiodol incorporated in P(SA:RA) is visible on CT, and polymer degradation can potentially be monitored noninvasively. This method can be widely applied to follow changes in biodegradable implants.

Irreversible electroporation ablation: creation of large-volume ablation zones in in vivo porcine liver with four-electrode arrays.

PURPOSE: To prospectively determine optimal parameters with which to achieve defined large target zones of coagulation by using irreversible electroporation (IRE) with four-electrode arrays and the time needed to achieve this treatment effect in an in vivo animal model. MATERIALS AND METHODS: This study was approved by the animal care and use committee. Ultrasonography (US)-guided IRE ablation (n = 90) was performed in vivo in 69 pig livers with an array of four electrodes (18 gauge) and an electroporation generator. Cardiac-gated 100-µsec IRE pulses were applied sequentially between the six sets of electrode pairs at 2250-3000 V. Multiple algorithms of energy deposition and electrode configuration were studied, including interelectrode spacing (1.5-2.5 cm), number of IRE pulses applied consecutively to each electrode pair (10, 20, 50, and 100), and number of times per cycle each electrode pair was activated (one to 10). Resultant zones of treatment were measured with US 1.5-3 hours after IRE and confirmed at gross and histopathologic examination. Data and ablation times were compared to determine the optimal algorithms with which to achieve 4-7-cm areas of treatment effect in the shortest time possible. In addition, the IRE current applied was correlated with ablation size. Data were analyzed by using analysis of variance with multiple comparisons, t tests, or nonparametric statistics. RESULTS: For 2.5-cm spacing, ablation diameter was increased by increasing either the overall time of energy application or the number of cycles of 20 pulses (P < .01 for both). IRE application of less than four cycles (or continuous IRE application of 100 pulses) did not result in contiguous ablation. However, sequentially increasing the number of cycles of IRE from four to 10 increased both the electrical current applied (from 14.4 A ± 0.4 to 17.6 A ± 0.7, P = .0004) and ablation diameter (from 5.6 cm ± 0.3 to 6.6 cm ± 0.3, P = .001). Although division of application into cycles did not alter coagulation at 2.0- and 1.5-cm spacing, application of energy to diagonal electrode pairs increased coagulation. Thus, one 100-pulse cycle (11.0 minutes ± 1.4) produced 4.8 cm ± 0.3 of ablation for 2.0-cm spacing with diagonal pairs but only 4.1 cm ± 0.3 of ablation without diagonal pairs (7.5 minutes ± 1.0, P < .03 for both). CONCLUSION: With four-electrode arrays, IRE can create large contiguous zones of treatment effect in clinically acceptable ablation times; parameters can be tailored to achieve a wide range of ablation sizes. Cyclical deposition of IRE application is beneficial, particularly for larger interprobe spacing, most likely owing to alterations of electrical conductivity that occur after successive applications of IRE energy.

Image-guided fusion and navigation: applications in tumor ablation.

Navigation technology and multimodality image fusion represent an important development in interventional radiology. It is a rapidly developing field with great promise for improving, optimizing, and refining our workflow, especially for performing complex and difficult biopsies and ablations. It can potentially reduce procedure time, radiation dose, and complications while enhancing procedure accuracy and effectiveness. Additionally, such techniques are likely to greatly benefit less experienced operators and shorten the long learning curve to mastery of conventional procedures. Here, we describe different aspects of currently available image-guided fusion devices including the types of clinically available technological platforms (electromagnetic vs optical fusion) used to fuse prior and real-time images; pretest planning software; and advantages and limitations reported in preclinical and emerging clinical studies. Much refinement and development still needs to be performed for both the tracking systems and preablation software predictability, but this is anticipated as substantial research within the framework of multiple academic industrial partnerships is ongoing.

Irreversible electroporation: treatment effect is susceptible to local environment and tissue properties.

PURPOSE: To study the effects of the surrounding electrical microenvironment and local tissue parameters on the electrical parameters and outcome of irreversible electroporation (IRE) ablation in porcine muscle, kidney, and liver tissue. MATERIALS AND METHODS: Animal Care and Use Committee approval was obtained, and National Institutes of Health guidelines were followed. IRE ablation (n = 90) was applied in muscle (n = 44), kidney (n = 28), and liver (n = 18) tissue in 18 pigs. Two electrodes with tip exposure of 1.5-2 cm were used at varying voltages (1500-3000 V), pulse repetitions (n = 70-100), pulse length (70-100 µsec), and electrode spacing (1.5-2 cm). In muscle tissue, electrodes were placed exactly parallel, in plane, or perpendicular to paraspinal muscle fibers; in kidney tissue, in the cortex or adjacent to the renal medulla; and in liver tissue, with and without metallic or plastic plates placed 1-2 cm from electrodes. Ablation zones were determined at gross pathologic (90-120 minutes after IRE) and immunohistopathologic examination (6 hours after) for apoptosis and heat-shock protein markers. Multivariate analysis of variance with multiple comparisons and/or paired t tests and regression analysis were used for analysis. RESULTS: Mean (± standard deviation) ablation zones in muscle were 6.2 cm ± 0.3 × 4.2 cm ± 0.3 for parallel electrodes and 4.2 cm ± 0.8 × 3.0 cm ± 0.5 for in-plane application. Perpendicular orientation resulted in a cross-shaped zone. Orientation significantly affected IRE current applied (28.5-31.7A for parallel, 29.5-39.7A for perpendicular; P = .003). For kidney cortex, ovoid zones of 1.5 cm ± 0.1 × 0.5 cm ± 0.0 to 2.5 cm ± 0.1 × 1.3 cm ± 0.1 were seen. Placement of electrodes less than 5 mm from the medullary pyramids resulted in treatment effect arcing into the collecting system. For liver tissue, symmetric 2.7 cm ± 0.2 × 1.4 cm ± 0.3 coagulation areas were seen without the metallic plate but asymmetric coagulation was seen with the metallic plate. CONCLUSION: IRE treatment zones are sensitive to varying electrical conductivity in tissues. Electrode location, orientation, and heterogeneities in local environment must be considered in planning ablation treatment. Online supplemental material is available for this article.

Scrotal ultrasound in adults.

Scrotal ultrasound (US) is the technique of choice for imaging the scrotal contents. US is widely used in the characterization of scrotal pathologies as a supplement to the clinical examination. Modern US equipment, precise technical performance, and knowledge of sonographic anatomy and pathology, as in any US examination, are the basis for a correct diagnosis. New techniques, including elastography and contrast-enhanced US, may have an added value to the diagnosis.

Ocular melanoma metastasizing to intra-abdominal lymph nodes.

Background. Visceral metastatic spread of ocular melanoma most commonly occurs via hematogenous route to the liver. Lymphatic spread of ocular melanoma into abdominal lymph nodes has not been reported previously. Case Presentation. A 47-year-old man with a history of ocular melanoma presented with a soft tissue mass on CT scan. The mass encased the portal structures of the hepaticoduodenal ligament. Image-guided biopsy revealed it to be a metastatic melanoma to lymph nodes. The patient underwent surgery with the intent to prolong disease-free survival. On final pathological examination, two lymph nodes were found harboring metastatic melanoma. Conclusion. Extrahepatic lymphatic intra-abdominal spread of ocular melanoma is not impossible. Since this mode of spread is rare, the oncologic significance of surgical resection of isolated intra-abdominal nodal with metastatic ocular melanoma is difficult to determine at the present time.

The natural history of secondary muscle-invasive bladder cancer.

BACKGROUND: The management of patients with high-grade non muscle invasive bladder cancer (NMIBC) brings diagnostic and therapeutic challenges. In the current study, we sought to study the natural history of progression to "secondary" muscle-invasive bladder cancer (MIBC)-cancer that developed during follow up of patients presenting with non-muscle invasive bladder cancer (NMIBC). METHODS: Between 1998 and 2008, 760 patients were treated for bladder cancer. Primary MIBC (>=T2) tumors (present upon presentation) were diagnosed in 114 patients. All patients with high-grade NMIBC were treated with intravesical BCG. Mean follow-up was 44 months. RESULTS: Forty patients (6.1%) developed secondary MIBC after a mean period of 21 months from initial diagnosis of bladder cancer. The 2- and 5-year disease-specific survival rates were better for patients with secondary MIBC (90% and 56% compared to 69% and 42% for patients with primary disease, p=0.03). The Kaplan-Meier curves of the two groups were parallel but displaced by approximately 2 years. CONCLUSION: In the current series, MIBC progression occurred among initially presenting patients with NMIBC in 6.1%. In most patients, the initial diagnosis of NMIBC is correct and muscle invasion occurs after a mean period of about 2 years. This supports a non-radical approach in patients with high-grade T1, Ta or Tis. Meticulous follow-up with liberal biopsy of any suspicious lesion may provide early diagnosis of invasive disease.

TL-118-anti-angiogenic treatment in pancreatic cancer: a case report.

Pancreatic cancer is one of the most aggressive malignant tumors. In recent years, little progress has been made in understanding and treatment of the disease. The two most commonly used chemotherapy drugs approved for the treatment of pancreatic cancer are gemcitabine and fluorouracil. Anti-angiogenic treatment is one of the current promising approaches in cancer translational research. Its aim is to inhibit development of new blood vessels and thereby prevent further tumor growth. We present a first description of a pancreatic cancer patient treated with standard chemotherapy and TL-118, an anti-angiogenic combination of 4 drugs that target non-overlapping aspects of the angiogenic process (Provided by Tiltan Pharma Ltd for compassionate use). Our patient, treated with standard chemotherapy combined with TL-118, was diagnosed about 16 months ago and is still considered progression free, while being treated with that combination. Moreover, when the treatment with TL-118 was stopped, there was a clear elevation of tumor marker which dropped again with the renewal of TL-118. This effect was not achieved by gemcitabine treatment alone. Recently, a phase II clinical trial of TL-118 for pancreatic cancer patients that have not yet been treated with chemotherapy was initiated. (Tiltan Pharma Ltd). The study objective is to evaluate the efficacy, safety, and tolerability of TL-118 in gemcitabine-treated metastatic pancreatic cancer patients. This report describes a new approach in treating pancreatic cancer, enabling patients to obtain a longer progression-free survival using this new anti-angiogenic drug combination, added on standard chemotherapy.

Evaluation of an electromagnetic image-fusion navigation system for biopsy of small lesions: assessment of accuracy in an in vivo swine model.

PURPOSE: To evaluate the accuracy of a novel combined electromagnetic (EM) navigation/image fusion system for biopsy of small lesions. MATERIALS AND METHODS: Using ultrasound (US) guidance, metallic (2 × 1 mm) targets were imbedded in the paraspinal muscle (n = 28), kidney (n = 18), and liver (n = 4) of four 55- to 65-kg pigs. Baseline helical computed tomography (CT) imaging (Brilliance; Philips) identified these biopsy targets and six and nine cutaneous fiducial markers. CT data were imported into a MyLab Twice system (Esaote, Genoa, Italy) for CT/US image fusion. After verification of successful image fusion, baseline registration error and respiratory motion error were assessed by documenting deviation of the US and CT position of the targets in real time. Biopsy targeting was subsequently performed under conditions of normal respiratory using 15-cm 16G eTrax needles (Civco). To mimic the conditions of poor US visualization, only reconstructed CT information was displayed during biopsy. Accuracy of targeting was measured by repeat CT scanning as the distance of the needle tip to the target center. Targeting accuracy of free-hand vs. guided technique, and electromagnetic (EM) sensor positioning (ie, on the hub or within the needle stylus tip) were evaluated. RESULTS: In muscle, needle registration error was 0.9 ± 1.2 mm and respiratory motion error 4.0 ± 1.0 mm. Target accuracy was 4.0 ± 3.2 mm when an EM sensor was imbedded in the needle tip. Yet, with the EM sensor back on the needle hub, greater targeting accuracy was achieved using an US guide (3.2 ± 1.6 mm) vs. freehand (5.7 ± 3.2 mm, P = .04). For kidney, registration error was 1.8 ± 1.7 mm and respiratory motion error 4.9 ± 1.0 mm. For the deeper kidney targets, target accuracy was 4.4 ± 3.2 mm with a tip EM sensor, which was an improvement over the hub EM sensor positioning (9.3 ± 4.6 mm; P < .01). An additional source of fusion error was noted for liver. Beyond 17 ± 1 mm of respiratory motion, targets were observed to move >3 cm with US transducer/needle compression resulting in 14 ± 1.4 mm targeting accuracy. CONCLUSIONS: A combined image-fusion/EM tracking platform can provide a high degree of needle placement accuracy (<5 mm) when targeting small lesions. Results fall within accuracy of respiratory error; with best results obtained by incorporating an EM sensor into the tip of the biopsy system.