Selecting the Appropriate Downstaging and Bridging Therapies for Hepatocellular Carcinoma: What Is the Role of Transarterial Radioembolization? A Pooled Analysis.

BACKGROUND: Transarterial radioembolization in HCC for LT as downstaging/bridging has been increasing in recent years but some indication criteria are still unclear. METHODS: We conducted a systematic literature search of primary research publications conducted in PubMed, Scopus and ScienceDirect databases until November 2022. Relevant data about patient selection, HCC features and oncological outcomes after TARE for downstaging or bridging in LT were analyzed. RESULTS: A total of 14 studies were included (7 downstaging, 3 bridging and 4 mixed downstaging and bridging). The proportion of whole liver TARE was between 0 and 1.6%. Multiple TARE interventions were necessary for 16.7% up to 28% of the patients. A total of 55 of 204 patients across all included studies undergoing TARE for downstaging were finally transplanted. The only RCT included presents a higher tumor response with the downstaging rate for LT of TARE than TACE (9/32 vs. 4/34, respectively). Grade 3 or 4 adverse effects rate were detected between 15 and 30% of patients. CONCLUSIONS: TARE is a safe therapeutic option with potential advantages in its capacity to necrotize and reduce the size of the HCC for downstaging or bridging in LT.

Preoperative transarterial chemoembolization for laparoscopic liver resection in Child A cirrhotic patients with hepatocellular carcinoma.

PURPOSE: Laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) offers better short-term results than open surgery with similar long-term results although it is technically difficult due to the risk of bleeding. METHODS: This study included patients with HCC in Child A cirrhosis who underwent TACE before LLR between 2009 and 2019. The primary endpoint was to analyze the intraoperative and early results of this technique. We also analyzed the long-term outcomes. Patients with and without clinically significant portal hypertension (CSPH) were compared. RESULTS: A total of 44 cirrhotic patients with HCC were included (24 CSPH and 20 non-CSPH). The Pringle maneuver was used in two cases (4.5%), mean blood losses was 100 ml (range 50-200), and three patients (6.8%) required a blood transfusion. The degree of necrosis achieved was greater than 90% in 27 patients (61.4%). At 1, 3, and 5 years, overall survival was 97.7%, 81.5%, and 63.4%, respectively, and disease-free survival was 85.2%, 52.5%, and 34.5%, respectively. There were no statistically significant differences between non-CSPH and CSPH groups regarding intraoperative, early, and long-term outcomes. CONCLUSION: In our experience, TACE could be beneficial to perform LLR in HCC Child-Pugh A patients with and without CSPH without serious complications and similar oncological outcomes.

Derivación portosistémica intrahepática transyugular (TIPS) en España. Consideraciones clínicas-epidemiológicas en relación a un registro multicéntrico / No disponible

OBJETIVO: el objetivo del presente estudio es conocer aspectos epidemiológicos, técnicos y clínicos en el uso de la derivación portosistémica intrahepática transyugular (TIPS) en España en las unidades de intervencionismo. Además, se compara el número de TIPS realizados en España con el de otros países. MATERIAL Y MÉTODOS: estudio retrospectivo aprobado por el Comité Ético de la Sociedad Española de Radiología Intervencionista (SERVE). Para la recolección de datos sobre el estado actual del TIPS en España, se preparó una encuesta con 31 ítems (datos demográficos, técnicos y clínicos). La encuesta fue enviada a los 49 hospitales que constaba en el registro de la SERVEI que en 2016 habían realizado TIPS. RESULTADOS: de los 49 centros encuestados, 33 (67,35 %) respondieron. Estos centros habían realizado 265 de los 415 TIPS realizados ese año en España. La indicación más frecuente fue el sangrado por varices gastroesofágicas (144, 54,33 %). El 62,26 % de los TIPS fueron realizados de forma urgente y el 37,7 %, de forma programada. El éxito técnico fue de 89,16 ± 20,9 %, resangrando entre ellos el 17,9 %. Sesenta y nueve pacientes (26,03 %) presentaron complicaciones (el 19,62 % menores y el 6,41 % mayores). La mortalidad a 30 días relacionada con la enfermedad fue del 14,33 %, mientras que a un año fue del 18,49 %. CONCLUSIÓN: de forma llamativa, en nuestro estudio, las complicaciones del TIPS no muestran una clara relación con el número de procedimientos realizados. En relación a otros países como Estados Unidos y Francia, el número de TIPS en España por millón de habitantes actualmente es sustancialmente menor, sin cambios significativos respecto al número realizado en 2013

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Absorbable stents for treatment of benign biliary strictures: long-term follow-up in the prospective Spanish registry.

OBJECTIVES: Benign strictures of the bile duct may be difficult to treat endoscopically due to altered bowel anatomy. Furthermore, recurrence of stenosis and symptoms remains high. The aim of the Spanish Prospective Registry BiELLA study was to investigate the safety and efficacy of absorbable stents in the treatment of benign biliary strictures and their outcomes on the medium and long-term follow-up. METHODS: A prospective, multicenter, observational, non-randomized study (the BiELLA study) was conducted from January 2014 to September 2018. One hundred fifty-nine patients with benign biliary strictures, mostly postsurgical, were enrolled for implantation of absorbable biliary stents in the 11 participating Spanish tertiary hospitals. The average patient follow-up was 45.4 ± 15.9 months (range, 12-60 months). The follow-up data included symptoms, biochemical parameters, and ultrasound images at 1, 6, and 12 months and then yearly for up to 60 months. RESULTS: The immediate technical and clinical success rates were 100%. In all patients, stent placement resulted in improvement of clinical symptoms and biochemical parameters. The primary mean patency for stent was 86.7, 79.6, and 78.9% at 12, 36, and 60 months, respectively (95% CI). Biliary restenosis and occlusion occurred in 40 (26.6%) patients. Of the 40 patients, 18 (12%) patients were treated with a second stent and 22 (14.6%) patients had operative repair of the recurrent strictures. There were no major complications associated with stent implantation. CONCLUSIONS: Implantation of an absorbable polydioxanone biliary stent is safe and effective for treatment of benign biliary strictures refractory to balloon dilatation or other biliary intervention. KEY POINTS: • Percutaneous implantation of biodegradable prostheses for the treatment of benign postsurgical biliary strictures is a safe and effective procedure. • More than 75% of the patients presented patency of the stented biliary tree at 5 years follow-up. • Absorbable stents improved clinical symptoms and signs (jaundice, itching, fever), and laboratory parameters in a few days after stent placement.

Embolización de seudoaneurisma femoral secundario a contusión por asta de toro / Embolization of femoral pseudoaneurysm secondary to contusion by bull horn

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Successful embolization of a cytomegalovirus-related duodenal ulcer in a kidney-pancreas transplant recipient.

One of the complications that can occur in pancreas transplant is a massive intestinal hemorrhage, although such a hemorrhage is very rarely caused by ulcers due to cytomegalovirus infection. Treatment is fundamentally based on relaparatomy, although in some cases interventional radiology can be an efficient alternative because it allows the exact bleeding point to be located and therapeutic embolization to be performed. In this case, a man with diabetes type 1 who was given a simultaneous kidney-pancreas transplant had an ulcer due to cytomegalovirus infection develop in the duodenal graft (in the early postoperative period), causing a severe hemorrhage in the lower part of the gastrointestinal tract that was controlled via selective embolization of a branch of the pancreaticoduodenal artery.

Effectiveness and safety of doxorubicin loaded beads in hepatocellular carcinoma.

BACKGROUND: Transarterial chemoembolization using microspheres is a new treatment option for patients with hepatocellular carcinoma. OBJECTIVE: To assess the effectiveness of this technique, in terms of tumor response and overall survival rates, and to assess the procedure's safety. SETTING: A General University Hospital in Spain. METHODS: Single-center retrospective observational study. The cohort included all patients treated between October 2006 and April 2010. Effectiveness was determined by the tumor response rate (using modified RECIST and EASL criteria) and overall survival. Safety was assessed according to the Common Terminology Criteria for Adverse Events. MAIN OUTCOME MEASURE: Tumor response rate, overall survival and safety of transarterial chemoembolization in patients with hepatocellular carcinoma. RESULTS: 53 patients were treated (81.1 % men, median age 65). Baseline characteristics 98.1 % had cirrhosis, 75.5 % Child-Pugh Class A, 71.7 % Okuda I, and 94.3 % were ECOG 0. 43.4 % were waiting for a liver transplant and 56.6 % were given the treatment as a palliative measure. Eighty-one procedures were carried out, with a median of 1 per patient [1-5]. Four weeks after treatment, the objective response rate was 87.5 % and the complete response rate was 62.5 %. Median survival was 735 days (CI 95 %: 351.9-1118.1). The 1, 2 and 3-year overall survival rates were 65.4, 50.9 and 42.5 %, respectively. 71.7 % of patients experienced post-embolization syndrome, with grade 1 abdominal pain as the most frequent symptom (37.7 %). CONCLUSION: This study provides new evidence of the safety and effectiveness of transarterial chemoembolization using doxorubicin-loaded microspheres for the treatment of hepatocellular carcinoma in patients who are not eligible for other treatments, or as a bridging treatment in patients on the liver transplant waiting list.

IMRT: preliminary results in a series of advanced head-and-neck cancer patients.

PURPOSE: To determine retrospectively 2-3 year local and regional control (LRC), free-of-disease survival (FDS) and overall survival (OS), as well as summarized toxicities in a group of 31 advanced head-and-neck cancer patients, treated at our institution between 2004 and 2011 with definitive IMRT low-dose concomitant boost, the majority of them with concurrent chemotherapy based on cisplatin. The results are also shown in the sub-group of nasopharyngeal cancer patients (NPC: 15 cases). PATIENTS AND METHODS: Radiological basal and contrasted CT series, MR-CT or PET/CT fused images in the setup position with immobilization mask were registered in simulation therapy patients. Planed doses were: 70 Gy in primary tumor and positive nodes >1 cm; 63 Gy in high-risk areas of microscopic diseases +10 mm safety margin; and 56 Gy in low risk of diseases regional lymph nodes. Treatment was delivered using a Varian 2100 Clinac with sliding windows IMRT. Spinal cord doses were limited to a strict maximum of 45 Gy, and optimization aimed for mean doses in parotid glands below 26 Gy, especially in the contralateral parotid gland. Online DRR-portal X-ray comparison images were taken every day with a deviation module tolerance ≤3 mm. RESULTS: The mean follow-up since IMRT was 34 months (interval: 8-89; median 31 months). Median follow-up in living patients was 22 months. The 2-year rate for global LRC was 64 %, for FDS 61 % and OS 77 %. For the NPC group after 2 years, LRC was 73 %, FDS 73 % and OS 93 %. The 3-year rates were similar. Seven patients died as a consequence of local and/or regional progression (mean time 10 months). Relapses were observed in eight patients (26 %), but only seven could be confirmed by biopsy (22.6 %; mean time to relapse: 8.6 months). Global acute mucositis was 61 % and chronic mucositis was shown in six cases which developed xerostomia (19 %) in the first control after IMRT, but 1 year later it was reduced to only four patients, two Grade 2 and two Grade 1. CONCLUSIONS: No excessive, unwarranted toxicities were observed using concomitant low doses boost in IMRT. High rates of compliance to concurrent chemotherapy were achieved. Late xerostomia associated with this regime decreased 1 year after conclusion of treatment. The implementation of IMRT requires advances in imaging for better tumor delineation; otherwise the physician loses the advantage of dose modulation or faces a risk of geographical miss.

Quimioembolización previa a la resección hepática laparoscópica en el carcinoma hepatocelular precoz en pacientes cirróticos / Chemical embolisation before laparoscopic hepatic resection in early hepatocellular carcinoma in cirrhotic patients

La resección hepática por laparoscopia del hepatocarcinoma sobre cirrosis podría asociarse a un mayor riesgo de hemorragia y a un mayor uso de la maniobra de Pringle que cuando se realiza por vía abierta. Objetivo Valorar si la quimioembolización intraarterial preoperatoria (QMEP) reduce la hemorragia durante la resección laparoscópica y se evita así el empleo de la maniobra de Pringle y sus posibles complicaciones. Pacientes y métodos Se presentan 3 pacientes con cirrosis Child A con carcinoma hepatocelular (CHC) precoz, a los que se practicó QMEP de los segmentos por resecar. Todos los nódulos se localizaron en el lóbulo hepático derecho. Un caso fue intervenido por cirugía totalmente laparoscópica y los 2 restantes se convirtieron a cirugía laparoscópica asistida con la mano. En un caso se realizó bisegmentectomía VI–VII, en otro se realizó segmentectomía VI más radiofrecuencia de un segundo nódulo en segmento VII, y en el otro caso se realizó segmentectomía V. Resultados No hubo morbimortalidad. No se transfundió ningún paciente, las pérdidas hemáticas fueron de 100, 50 y 150ml, respectivamente, y no fue necesaria la maniobra de Pringle. La resección se completó en los 3 casos con un margen superior a 1cm y la estancia hospitalaria fue de 3, 3 y 4 días, respectivamente. Conclusión La QMEP permite realizar la resección laparoscópica del CHC sobre cirrosis con pocas pérdidas hemáticas sin el uso de la maniobra de Pringle. Estudios prospectivos aleatorizados son necesarios con un mayor número de pacientes para evaluar esta técnica (AU)

Objective To assess whether preoperative transarterial chemoembolisation (TACE) reduces haemorrhage during laparoscopic resection, thus making the Pringle manoeuvre unnecessary and avoiding any subsequent complications. Patients and methods We present 3 cirrhotic Child A patients with early hepatocellular carcinoma, all of whom had been given the same treatment involving resection by laparoscopy and preoperative TACE of the segments to remove. All the nodules were located in the right hepatic lobe. One case was treated using total laparoscopic surgery and the two remaining cases were converted to the hand-assisted technique. In the first case we carried out bisegmentectomy VI–VII; in the second, segmentectomy VI plus radiofrequency of a second nodule in segment VII, and in the third case, segmentectomy V.ResultsThere was no morbidity or mortality. Blood transfusion was not required by any of the patients; in fact blood losses were 100, 50 and 150ml, respectively, and it was not necessary to carry out the Pringle manoeuvre. Surgical margin was greater than 1cm in the three cases and hospital stay was less than 3, 3 and 4 days, respectively. Conclusion TACE prior to early hepatocellular carcinoma resection in cirrhotic patients seems to improve surgical safety with low blood losses without the use of the Pringle manoeuvre. Prospective random studies should be carried out on a larger number of patients in order to assess this technique (AU)

[Chemical embolisation before laparoscopic hepatic resection in early hepatocellular carcinoma in cirrhotic patients]. / Quimioembolización previa a la resección hepática laparoscópica en el carcinoma hepatocelular precoz en pacientes cirróticos.

OBJECTIVE: To assess whether preoperative transarterial chemoembolisation (TACE) reduces haemorrhage during laparoscopic resection, thus making the Pringle manoeuvre unnecessary and avoiding any subsequent complications. PATIENTS AND METHODS: We present 3 cirrhotic Child A patients with early hepatocellular carcinoma, all of whom had been given the same treatment involving resection by laparoscopy and preoperative TACE of the segments to remove. All the nodules were located in the right hepatic lobe. One case was treated using total laparoscopic surgery and the two remaining cases were converted to the hand-assisted technique. In the first case we carried out bisegmentectomy VI-VII; in the second, segmentectomy VI plus radiofrequency of a second nodule in segment VII, and in the third case, segmentectomy V. RESULTS: There was no morbidity or mortality. Blood transfusion was not required by any of the patients; in fact blood losses were 100, 50 and 150 ml, respectively, and it was not necessary to carry out the Pringle manoeuvre. Surgical margin was greater than 1cm in the three cases and hospital stay was less than 3, 3 and 4 days, respectively. CONCLUSION: TACE prior to early hepatocellular carcinoma resection in cirrhotic patients seems to improve surgical safety with low blood losses without the use of the Pringle manoeuvre. Prospective random studies should be carried out on a larger number of patients in order to assess this technique.

Magnetic resonance study of lumbar disks in female dancers.

BACKGROUND: Previous imaging studies have shown that degenerative disk disease is more common in the competitive female gymnast than in asymptomatic nonathletic people of the same age training to any degree. However, results of exposure-discordant monozygotic and classic twin studies suggest that physical loading specific to occupation and sport has a relatively minor role in disk degeneration, beyond that of upright postures and routine activities of daily living. HYPOTHESIS: Intensive, regular, and prolonged dancing causes strain on the lumbar spine and can trigger or accelerate the development of degenerative diskopathy. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Forty volunteer female dancers (20 ballet and 20 flamenco) aged between 18 and 31 years (mean = 24.2) underwent magnetic resonance imaging of the lumbar spine. They were compared against a control group of 20 women of the same age. A descriptive analysis was done, and the 2 groups were compared by contingency table analysis using the Pearson chi-square test complemented by an analysis of residuals. Results Nine of the 20 women (45%) in the control group had disk degeneration compared with 13 of the 40 (32.5%) women in the dancer group, with a chi-square of 0.897 (not significant). There were 12 degenerated disks of the 100 explored (12%) in the control group compared with 21 of the 200 explored (10.5%) in the dancer group (chi-square = 0.153; not significant). CONCLUSION: Dancing cannot be considered a risk factor for lumbar disk degeneration in women. CLINICAL RELEVANCE: The present study indicates that dancing has no negative effect on the development of degenerative diskopathy.

Cálculo del volumen hepático mediante TC espiral: utilidad en la planificación de la resección hepática mayor en pacientes no cirróticos / Utility of spiral computed tomography calculation of hepatic volume in the planning of major liver resection in noncirrhotic patients

Introducción. Mediante tomografía computarizada (TC) espiral es posible estimar la extensión de la resección hepática preoperatoriamente y seleccionar a los pacientes que presentan mayor riesgo de insuficiencia hepática posquirúrgica. El objetivo de este estudio es determinar de forma prospectiva la utilidad de la estimación del volumen hepático residual (VHR) mediante TC espiral en la planificación de la resección hepática mayor (RHM) en pacientes no cirróticos. Pacientes y método. Entre septiembre de 2000 y marzo de 2003 se calculó el volumen hepático total (VHT) y el VHR en 31 pacientes como parte de la planificación preoperatoria de una RHM. En los pacientes con un porcentaje de VHR/VHT menor del 25 por ciento se realizó una oclusión portal derecha preoperatoria. Resultados. En 7 pacientes, el porcentaje de VHR/VHT fue menor del 25 por ciento. En 2 posibles donantes vivos la resección estaba contraindicada. En los 5 restantes, tras la oclusión portal se consiguió suficiente hipertrofia del hígado izquierdo para indicar la RHM. Conclusión. La medida del VHR afectó a la decisión quirúrgica, al seleccionar los pacientes en los que es posible realizar una resección segura. En caso de quedar escaso hígado residual, las técnicas de embolización preoperatoria o ligadura intraoperatoria de vena porta han resultado ser un buen procedimiento para incrementarlo (AU)

Endovascular repair of concomitant celiac trunk and abdominal aortic aneurysms in a patient with Behçet's disease.

PURPOSE: To report endovascular repair of dual aneurysms in a patient with Behçet's disease. CASE REPORT: A 37-year-old man diagnosed 6 months prior with Behçet's disease presented with a pulsating abdominal mass. Computed tomography revealed a 70-mm-diameter pseudoaneurysm in the abdominal aorta and another (20 mm) in the celiac trunk 5 mm from the aorta. Staged endovascular repair began with the aortic aneurysm, which was excluded with a bifurcated 23 x 140-mm Excluder stent-graft. Three days later, 2 Jostent stent-grafts were placed in the celiac trunk, successfully excluding the lesion. Fifteen days later, the patient was discharged on a regimen of clopidogrel, cyclosporine, and warfarin. At 6 months, the CT scan showed good perfusion of the stent-grafts. CONCLUSIONS: Aneurysmal involvement of the celiac trunk in a patient with Behçet's disease is a rare pathology that appears amenable to stent-graft repair.

Tetralogía de fallot en el adulto complicada con hemoptisis grave. Tratamiento mediante embolización de la arteria tirocervical izquierda / Fallot Tetralogy Complicated with Severe Hemoptysis in the Adult

La tetralogía de Fallot con atresia pulmonar constituye una situación especial en la que se permite la supervivencia hasta la edad adulta. En estos casos se desarrollan complicaciones, como la hemoptisis, que comprometen la vida del paciente y tienen difícil tratamiento. Cuando la causa del sangrado es la rotura de cortocircuitos arteriovenosos, frecuentes en las malformaciones vasculares múltiples que se originan en esta cardiopatía, la embolización selectiva de estas malformaciones puede ser una opción eficaz de tratamiento (AU)