Acetic acid versus radiofrequency ablation for the treatment of hepatocellular carcinoma: A randomized controlled trial.

PURPOSE: The purpose of this prospective study was to compare the efficacy of percutaneous acetic acid (PAAI) to that of radiofrequency ablation (RFA) in the treatment of small (≤5cm) hepatocellular carcinoma (HCC) using a randomized trial. MATERIAL AND METHODS: Consecutive patients with small HCC underwent clinical, biochemical, and imaging evaluation. Those fulfilling the inclusion criteria (Child's A/B cirrhosis, less than 5 HCC nodules, HCC nodules≤5cm diameter, no extrahepatic disease, patent portal vein, normal coagulation profile with informed consent) were randomly assigned to receive RFA or PAAI. Tumor response and survival rate were estimated. Non-inferiority margin of 10% difference was taken for effectivity of PAAI compared to RFA. RESULTS: Of the 86 patients screened, 55 patients with 67 HCC nodules were included. There were 40 men and 15 women with a mean age of 54.3±10.5 (SD) years (range: 28-71years). Of these, 26 patients had PAAI and 29 had RFA. The clinical, demographic and imaging profiles of the two groups were similar. Complete response was non-inferior to RFA [PAAI 75% and RFA 83.3%, difference 8.3% CI (-12.5% to 29.2%)]. Lower limit of this 95% CI (-12.5%) was lower than the 10% non-inferiority margin difference (8.3%). Survival rates were similar at 12months (PAAI, 81.6% vs. RFA, 71.9%; P=0.68) and at 30months (PAAI, 54.4% vs. RFA, 52%; P=0.50). CONCLUSION: PAAI and RFA have similar efficacy in treating small HCC. PAAI could thus be a cost-effective alternative in situations where RFA is either unavailable or unaffordable.

Chilaiditi's sign possibly associated with malposition of chest tube placement.

Although diaphragmatic paralysis is a rare recognized complication of chest tube malposition, Chilaiditi's sign occurring as a result of this complication has never been reported in literature to the best of our knowledge. We describe one such case, which had an interesting clinical sequence of events and radiographic findings and suggest that the medial end of the chest tube should be positioned at least 2 cm from the mediastinum on the frontal chest radiograph to avoid these complications.

High resolution CT (HRCT) in miliary tuberculosis (MTB) of the lung: Correlation with pulmonary function tests & gas exchange parameters in north Indian patients.

BACKGROUND & OBJECTIVE: High resolution computed tomography (HRCT) scans are known to be helpful in early diagnosis and management of patients with miliary tuberculosis (MTB). We made an attempt in this study to identify patterns of pulmonary MTB on HRCT and to correlate the HRCT disease extent with pulmonary function tests (PFT) and gas exchange analysis (GEA). METHODS: A total of 16 non-HIV patients with MTB underwent HRCT of the chest, PFT and GEA. All the investigations in these patients were completed within 20 days of presentation. Evidence of TB was diagnosed by biopsy from lymph nodes (3/16), organ biopsy [skin, liver, bone marrow and lung (transbronchial) (6/16)]. In one patient fundoscopy revealed choroid tubercles. In 6 patients, diagnosis was confirmed by clinical/radiological improvement following anti-tuberculosis therapy. Radiological patterns of involvement on HRCT of the lungs were studied and disease extent was estimated in each case by consensus between two radiologists using specially devised visual scoring system. Disease extent was correlated with PFT and GEA. Spearman rank correlation was used for statistical analysis. RESULTS: Findings on HRCT in MTB included miliary nodularity (16/16), alveolar lesions such as ground glass attenuation and/or consolidation (5/16), lymphadenopathy (8/16), peribronchovascular interstitial thickening (1/16), emphysema (1/16), pleural pathology (2/16), and pericardial effusion (2/16). A significant correlation was noted between disease extent score and forced vital capacity (FVC) (r = -0.76; P=0.003), forced expiratory volume in one second (FEV(1))(r = -0.74; P = 0.005), total lung capacity (TLC) (r = -0.66; P = 0.037), oxygen saturation in arterial blood (SaO(2)) (r = -0.69, P = 0.01), diffusion capacity of the lung (DLco) (r = -0.8; P = 0.02). INTERPRETATION & CONCLUSION: Our findings showed that HRCT reliably diagnosed MTB, and thus could help in predicting derangement of pulmonary function tests and GEA in these patients.

CT enteroclysis in the diagnosis of obscure gastrointestinal bleeding: initial results.

AIM: To evaluate the usefulness of computed tomography (CT) enteroclysis in patients with obscure gastrointestinal (GI) bleeding. MATERIALS AND METHODS: In a prospective study, CT enteroclysis was performed in 21 patients (median age 50 years; range 13-71 years) with obscure GI bleeding in which the source of the bleeding could not be detected despite the patient having undergone both upper GI endoscopic and colonoscopic examinations. The entire abdomen and pelvis was examined in the arterial and venous phases using multisection CT after distending the small intestine with 2l of 0.5% methylcellulose as a neutral enteral contrast medium and the administration of 150ml intravenous contrast medium. RESULTS: Adequate distension of the small intestine was achieved in 20 of the 21 (95.2%) patients. Potential causes of GI bleeding were identified in 10 of the 21 (47.6%) patients using CT enteroclysis. The cause of the bleeding could be detected nine of 14 (64.3%) patients with overt, obscure GI bleeding. However, for patients with occult, obscure GI bleeding, the cause of the bleeding was identified in only one of the seven (14.3%) patients. The lesions identified by CT enteroclysis included small bowel tumours (n=2), small bowel intussusceptions (n=2), intestinal tuberculosis (n=2), and vascular lesions (n=3). All vascular lesions were seen equally well in both the arterial and venous phases. CONCLUSIONS: The success rate in detection of the cause of bleeding using CT enteroclysis was 47.6% in patients with obscure GI bleeding. The diagnostic yield was higher in patients with overt, obscure GI bleeding than in those with occult obscure GI bleeding.

Update in liver imaging.

Over the last decade, liver imaging has experienced a revolution providing a bewildering array of options for detection and characterisation of liver lesions. Cross-sectional imaging modalities like computed tomography and magnetic resonance imaging have improved in speed and resolution, thereby facilitating multiphasic scanning of the liver. The advent of the use of contrast agents for ultrasonography and magnetic resonance imaging has further paved the way for definitive diagnosis in an attempt to obviate the need for invasive diagnosis. This article captures advances made in ultrasonography, computed tomography, magnetic resonance imaging and positron emission tomography and brings the specialist up to date with the latest in liver imaging.

Percutaneous biliary internal decompression in a patient with simultaneous malignant biliary and duodenal obstruction and surgically modified anatomy.

Simultaneous involvement and obstruction of the common bile duct and the duodenum presents a difficult and challenging problem to the surgeon, the endoscopist and the interventional radiologist. In the case report we present here, the patient had had duodenal and biliary obstruction secondary to hepatic flexure adenocarcinoma and presented with recurrent obstructive jaundice. As the surgically modified anatomy precluded all conventional endoscopic and percutaneous approaches, it was necessary to use an improvised method of achieving biliary decompression.

Aortic aneurysm and dissection: evaluation with spiral CT angiography.

The study was undertaken for aortic evaluation and to see its usefulness for assessing aortic aneurysm, aortic dissection and pseudoaneurysm by spiral CT angiography (CTA). A total of 28 patients with aortic aneurysm (n=19), aortic dissection (n=5) and aortic pseudoaneurysm (n=4) were included. CTA findings were compared with ultrasonography in 14, digital subtraction angiography (DSA) in 14, MRI in 9; and surgical findings in 12 patients. CTA was an excellent imaging modality for comprehensive evaluation of aortic aneurysm, dissection and pseudoaneurysm combining the advantage of conventional contrast enhanced CT axial images and those of angiography in the form of 3D reformatted images.

Radiofrequency ablation: a new therapeutic modality for the management of hepatocellular cancer.

We report two patients of hepatocellular cancer who recently underwent radiofrequency ablation at our center. Both underwent successful ablation of the tumour requiring 1-2 sessions of upto 15 minutes. There were no post procedure complications. One of the patients had developed another lesion after 10 months of follow up and underwent another session of RFA, while the second patient is doing well after one year of the procedure.

Management of renal angiomyolipoma in complex clinical situations.

Renal angiomyolipoma (AML) is associated with complex clinical situations such as tumour in a solitary kidney, bilateral, large or multicentric tumours or those associated with tuberous sclerosis (TS) or pregnancy. Management in these situations may be challenging. Fifteen patients (20 kidneys) were admitted with symptomatic AML over last 10 years. Eleven patients had one or the other complicating factor. Ten patients had a tumour of >10 cm, 4 had TS, 5 had multiple and bilateral tumours, 1 patient was pregnant and 1 had a solitary functioning kidney. With the newer imaging modalities correct diagnosis was possible in 12 cases and renal cell carcinoma (RCC) was suspected in 3 cases. Selective angioembolization (SAE) was done in 3 patients, which successfully controlled bleeding in all. Nephron-sparing surgery (NSS) was performed in 5 patients. Total nephrectomy was done in 4 cases, in 3 due to suspicion of RCC and in 1 due to extensive involvement of the kidney. Three patients with multiple and bilateral tumours were chosen for conservative treatment and none developed recurrence of bleeding on strict follow-up. In a pregnant patient, bleeding was successfully controlled with angioembolization. However, 1 patient with a solitary functioning kidney with large-sized tumour (20 x 18 cm) underwent NSS. In conclusion, the basis of management of AML is preservation of renal tissue, which can be effectively achieved with SAE or NSS. In a solitary functioning kidney, NSS or SAE is the ideal treatment, if feasible. The patients in the TS group are usually more complicated and require life-long follow-up after initial management with NSS or SAE. Pregnant AML patients can be safely managed with SAE. Conservative treatment without any intervention and regular follow-up may be more helpful in some patients with multiple, bilateral extensive tumours.

MR spectrum in spinal dysraphism.

Spinal dysraphism is a general term which encompasses a wide variety of anomalies of the spine, all of which result from imperfect midline fusion of the embryonic neural tube. This term refers to large defects that involve the spine and not to small vertical clefts commonly seen within the spinal process of L5 or S1. We present a spectrum of MR imaging findings selected from a retrospective review of 100 patients of spinal dysraphism evaluated at our institution.

Elbow arthropathy in hemophilia.

Twenty-one affected elbows in 14 known hemophilic patients undergoing treatment at the Hemophilia Clinic of our institution between 1994 and 1997 were evaluated using the clinical evaluation score of the Orthopaedic Advisory Committee of the World Federation of Hemophilia and radiological examination using the Pettersson score. The mean age of patients was 16.2 years (range 10-25 years), and all patients except 1 had severe hemophilia with factor VIII levels less than 1% of normal. The mean duration of disease at the time of presentation was 12.8 years. The mean clinical score was 6, while the mean radiological score was 4.9. There was a positive correlation between the clinical and radiological scores (P < 0.0001). However, the clinical and radiological scores did not correlate with either duration of disease or joint bleeding score. Two new radiological signs of obliteration of the capitello-lateral epicondyle groove with rounding off of the lateral aspect of the distal humerus and lipping of the medial trochlear surface were also recognized in hemophilic arthropathy of the elbow.

Uterine arteriovenous malformations: the role of intravenous 'dual-phase' CT angiography.

The authors describe the use of dual-phase intravenous CT angiography of the pelvis in two female patients, who presented with ongoing excessive vaginal bleeding, to demonstrate large adnexal and uterine arteriovenous malformations (AVMs). Power Doppler was used as the initial modality to diagnose the AVMs. CT angiography, along with 3-D rendering in the form of maximum intensity projections and shaded surface display, were especially useful for anatomical conceptualization to the gynecologist. This greatly helped in the subsequent management in the form of therapeutic embolization in both patients by reducing the time, radiation dose, and contrast required for the procedure. Subsequent surgery, which was required in both patients (due to failed embolization), was also greatly aided by the demonstration of the exact extent of the AVMs on axial CT images. Thus, CT angiography emerged as an impressive non-invasive imaging modality for the complete evaluation and management of the uterine AVMs.

MR appearances in a case of femoral ecchinococcosis.

Magnetic resonance (MR) findings of a rare case of osseous echinococcosis with involvement of the femur are described. Attention is drawn to the typical MR appearances and therapeutic management.

Esophageal and gastric vasculature in children with extrahepatic portal hypertension: evaluation by intravenous CT portography.

PURPOSE: To compare the findings related to esophageal/gastric varices and congestive gastropathy on intravenous computed tomography (CT) portography (CTP) and upper gastrointestinal endoscopy (UGIE) in children with extrahepatic portal venous obstruction (EHO) presented with hematemesis. METHODS/MATERIALS: Fifty pediatric patients (age < 15 years) with EHO (initially diagnosed on abdominal ultrasound) presented with hematemesis and underwent UGIE and intravenous CTP using a helical CT scanner. Axial sections of 2 mm each were obtained with a collimation of 2 mm and a table feed of 3 mm. CTP findings on these axial sections were compared with UGIE (gold standard). RESULTS: The sensitivity of CTP for detection of esophageal varices, gastric varices, and gastropathy was 32/33 (97%), 38/40 (95%), and 30/32 (93%), respectively. CTP showed false positivity as well, which was 5/17 (29%), 2/10 (20%), and 13/17 (76%) for esophageal varices, gastric varices, and gastropathy, respectively. On follow-up UGIE, the endoscopic features appeared in 14/19 (74%) of false positive patients. Therefore, false positivity for all the parameters on CTP when compared to the initial UGIE represented the changes in vasculature before they were endoscopically manifest. CONCLUSIONS: CTP was likely to pick up changes in esophageal and gastric vasculature earlier than UGIE in children with EHO presented with hematemesis.