Minimally Invasive Treatment Options for Hepatic Uveal Melanoma Metastases.

Uveal melanoma is one of the most common primary intraocular malignancies that accounts for about 85% of all ocular melanomas. The pathophysiology of uveal melanoma is distinct from cutaneous melanoma and has separate tumor profiles. The management of uveal melanoma is largely dependent on the presence of metastases, which confers a poor prognosis with a one-year survival reaching only 15%. Although a better understanding of tumor biology has led to the development of novel pharmacologic agents, there is increasing demand for minimally invasive management of hepatic uveal melanoma metastases. Multiple studies have already summarized the systemic therapeutic options available for metastatic uveal melanoma. This review covers the current research for the most prevalent locoregional treatment options for metastatic uveal melanoma including percutaneous hepatic perfusion, immunoembolization, chemoembolization, thermal ablation, and radioembolization.

Patients with falls from standing height and head or neck injury may not require body CT in the absence of signs or symptoms of body injury.

PURPOSE: To determine the rate of clinically impactful body injury among patients who had a fall from standing height with an associated head/neck injury, but without evidence of body injury on physical exam or plain radiographs. We also examine surgical/endovascular intervention related to body injury and mortality rates for head/neck and body injury. METHODS: Retrospective study of 288 patients with CT evidence of acute head/neck injury that underwent body CT despite the absence of clinical or radiographic evidence of body injury. Predictor variables were age, sex, race/ethnicity, and body mass index (BMI). RESULTS: There were 11.5% (n = 33) with body injury on CT (n = 33). There were 3.1% (n = 9) with clinically impactful body injury. No patient had either surgical/endovascular intervention or mortality related to body injury. Additionally, 8.7% (n = 25) had mortality from head/neck injury. Increased age (OR = 1.05, 95% CI: 1.01, 1.08, p = 0.01) and overweight BMI (25-29.99 kg/m2) (OR = 2.85, 95% CI: 1.07, 7.62, p = 0.04) were each significantly associated with increased odds for mortality from head/neck injury. CONCLUSION: Patients with falls from standing height and known head/neck injury had a low rate of clinically impactful body injury. None of the studied variables were associated with increased risk of body injury in this patient population. The low rate of clinically impactful body injury and the lack of any mortality, procedure, or transfusion resulting from body injury suggest that body CT may not be necessary in patients with head/neck injury in the absence of clinical or radiographic evidence of body injury.

Hypertriglyceridemic Pancreatitis: Is Insulin Monotherapy A Feasible Therapeutic Option?

Hypertriglyceridemic pancreatitis (HTGP) is an uncommon but well-established clinical entity. Although the initial clinical features are similar to pancreatitis due to other etiologies, the severity of the disease and the risk of complications are higher in these patients. Prompt diagnosis and appropriate treatment are crucial in patients with hypertriglyceridemia-induced pancreatitis to avoid life-threatening complications. The initial conservative treatment is applied followed by additional specific therapies tailored to decrease serum triglyceride levels. This includes plasmapheresis, insulin, heparin infusion, and hemofiltration. After the acute episode, lifestyle modifications along with hypolipidemic medications should be initiated to prevent further events. Currently, there is paucity of the medical literature directly comparing different treatment modalities. This article illustrates the use of insulin therapy for HTGP as a feasible therapeutic choice. Randomized controlled trials are warranted to outline a generalized and efficient treatment for this serious disorder.

Hypertriglyceridemic Pancreatitis Treated with Insulin Therapy: A Comparative Review of 34 Cases.

Although the clinical presentation of hypertriglyceridemic pancreatitis is usually similar to other forms of acute pancreatitis, it is frequently associated with increased clinical severity and rate of complications. Therefore, appropriate and timely management is of paramount importance in these patients. We performed a structured literature search of the medical databases PubMed and Google Scholar, using the terms "hypertriglyceridemia," "acute pancreatitis," "insulin," and "treatment." In this search, we identified 34 cases of hypertriglyceridemia-related pancreatitis available in the full-text form in English. The data on patients' characteristics, epidemiology, clinical features, comorbid conditions, and diagnostic modalities were collected and summarized. This review illustrates that the use of insulin therapy with close monitoring of blood glucose levels is safe. It can be considered as an important component of management in patients with hypertriglyceridemia-related pancreatitis, especially in a clinical setting without the availability of plasmapheresis. Randomized clinical trials are warranted to outline a generalized and efficient treatment regimen for hypertriglyceridemic pancreatitis.

Management of Difficult Access during Endovascular Aneurysm Repair.

BACKGROUND: To describe a large single-institutional experience in managing challenging access situations during endovascular aneurysm repair (EVAR). METHODS: Data from all patients undergoing EVAR at a tertiary academic medical center between 2009 and 2013 were collected retrospectively, including demographics, size of iliac arteries, type of device used, approach to managing difficult access (DA), and outcomes. The median follow-up was 38 months. DA was defined as iliac arteries with a diameter of less than 7 mm bilaterally. Fenestrated and snorkel repairs were excluded. RESULTS: Of 400 EVARs performed during the study period, 191 (48%) were done in patients with DA. Of the DA patients, 35 (18.3%) underwent 42 adjuncts before the introduction of the main body device: including 15 dilators, 11 balloon angioplasties, 9 aortouniiliac devices, 3 SoloPath sheaths, 1 retroperitoneal cutdown, and 3 iliac stents. In another 29 patients, iliac stents were used to correct stenoses or kinks in the limbs after EVAR devices were deployed. The average diameter of the iliac artery used to deliver main body component was 4.6 mm in the group of patients requiring adjuncts and 5.4 mm in the remainder of the patients with small iliac arteries (P = 0.008). The median size of the main body device was 28 mm. Two cases were aborted due to inability to deliver the device. Other complications included 7 (3.6%) iliac ruptures, 3 (1.6%) instances of limb ischemia, and 5 (2.6%) patients needed early reoperation (within 30 days). Two patients (1%) had type I endoleaks at the conclusion of EVAR. During follow-up, 12 (6.3%) patients required EVAR revisions. Seven patients (3.6%) had limb thrombosis which occurred only in patients who did not have adjective procedures during the initial EVAR. Limb thrombosis and rate of revisions in patients with DA were not significantly different from the rates observed in non-DA patients. Perioperative mortality after elective repairs was 1.6% in DA patients and 0% in non-DA patients (P = 0.12). CONCLUSIONS: EVAR can be successfully performed in patients with bilateral small iliac arteries. Adjunctive procedures might increase the technical success rate of EVAR in these patients and should definitely be considered in patients with iliac arteries less than 5 mm in diameter. Next generation and "low-profile" devices might minimize the need for adjunctive procedures and facilitate EVAR in these patients.

Multiparametric whole-body anatomic, functional, and metabolic imaging characteristics of peripheral lesions in patients with schwannomatosis.

PURPOSE: To describe the anatomic, functional, and metabolic characteristics of peripheral nerve sheath tumors (PNSTs) in patients with schwannomatosis (SWN) on whole-body magnetic resonance imaging (WB-MRI) (anatomic and functional imaging) and fluorine-18-fluorodeoxyglucose positron emission tomography / computed tomography (FDG-PET/CT) (metabolic imaging). MATERIALS AND METHODS: WB-MRIs at 1.5T and 3.0T performed in 13 SWN subjects using short tau inversion recovery (STIR), T1 -weighted (T1 W), contrast-enhanced T1 W, and diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) mapping and FDG-PET/CT were retrospectively reviewed. Two readers reviewed all imaging for the presence and character of peripheral lesions (size, imaging features, ADC values, and standardized uptake values [SUVmax ]) and ancillary findings. Descriptive statistics are reported. RESULTS: In all, 153 index lesions were characterized in 13 patients on WB-MRI. Lesions were characterized as tumors (97% [149/153]) or cysts (3% [4/153]); 96% (143/149) PNSTs were solitary while 4% (6/149) were plexiform. The median size was 2.3 cm (range 1-24.3 cm). On T1 W, 99% (148/149) tumors were homogeneously isointense; on STIR, 81% (121/149) tumors were heterogeneously hyperintense; on postcontrast T1 W, 81% (100/123) tumors enhanced heterogeneously; on DWI, tumor ADC values (×10(-3) mm(2) /s) were variable (minimum ADC range 0.3-2.2, average ADC range 0.9-2.9). The median SUVmax was 6 (range 2.1-11.7) and 10 (2.7-15.3) on early and delayed imaging, respectively. Malignant degeneration was detected in 1% (1/149) with suspicious anatomic, functional, and metabolic characteristics. Ancillary findings included nerve root thickening (23% [3/13]) and spinal canal lesions (15% [2/13]). CONCLUSION: Although the majority of the PNSTs in SWN are benign and solitary, PNSTs can be plexiform, enlarge over time, and, rarely, undergo malignant degeneration. Due to the high metabolic activity in benign PNSTs by FDG-PET/CT in SWN, WB-MRI with functional sequences maybe a more suitable technique for the assessment of disease burden, tumor characterization, and surveillance. J. MAGN. RESON. IMAGING 2016;44:794-803.

Markers of inflammation and fibrosis in alcoholic hepatitis and viral hepatitis C.

High levels of profibrinogenic cytokine transforming factor beta (TGF-ß), metalloprotease (MMP2), and tissue inhibitor of matrix metalloprotease 1 (TIMP1) contribute to fibrogenesis in hepatitis C virus (HCV) infection and in alcohol-induced liver disease (ALD). The aim of our study was to correlate noninvasive serum markers in ALD and HCV patients with various degrees of inflammation and fibrosis in their biopsies. Methods. Serum cytokines levels in HCV-infected individuals in the presence or absence of ALD were measured. Student's-t-test with Bonferroni correction determined the significance between the groups. Results. Both tumor-necrosis-factor- (TNF)-α and TGF-ß levels increased significantly with the severity of inflammation and fibrosis. TGF-ß levels increased significantly in ALD patients versus the HCV patients. Proinflammatory cytokines' responses to viral and/or toxic injury differed with the severity of liver inflammation. A combination of these markers was useful in predicting and diagnosing the stages of inflammation and fibrosis in HCV and ALD. Conclusion. Therapeutic monitoring of TGF-ß and metalloproteases provides important insights into fibrosis.