Optimized workflow to minimise intra-fractional motion during stereotactic body radiotherapy of spinal metastases.

Background and purpose: This study evaluated translational and rotational intra-fractional patient movement during spinal stereotactic body radiotherapy (SBRT) using 6D positioning based on 3D cone beam computerized tomography (CBCT) and stereoscopic kilovoltage imaging (ExacTrac). The aim was to determine whether additional intra-fractional image verification reduced intra-fractional motion without significantly prolonging treatment time, whilst maintaining acceptable imaging related dose. Materials and methods: A retrospective analysis of 38 patients with 41 primary tumour volumes treated with SBRT between September 2018 and May 2021 was performed. Three different image-guided radiotherapy (IGRT) workflows were assessed. The translational and rotational positioning errors for the different imaging workflows, 3D translational vectors and estimates of imaging dose delivered for the different imaging workflows were evaluated. Results: As the frequency of intra-fractional imaging increased from workflow 1 to 3, the mean intra-fraction 3D translational vector improved from 0.91 mm (±0.52 mm), to 0.64 (±0.34 mm). 85 %, 83 % and 97 % of images were within a tolerance of 1 mm/1° for workflows 1, 2 and 3 respectively, based on post treatment CBCT images. The average treatment time for workflow 3 was 13 min, as compared to 12 min for workflows 1 and 2. The effective dose per treatment for IGRT workflows 1, 2 and 3 measured 0.6 mSv, 0.95 mSv and 1.8 mSv respectively. Conclusion: The study demonstrated that the use of additional intra-fractional stereoscopic kilovoltage image-guidance during spinal SBRT, reduced the number of measurements deemed "out of tolerance" and treatment delivery could be optimized within a standard treatment timeslot without applying substantial additional radiation dose.

Liver resection and ablation for squamous cell carcinoma liver metastases.

BACKGROUND: Limited evidence exists to guide the management of patients with liver metastases from squamous cell carcinoma (SCC). The aim of this retrospective multicentre cohort study was to describe patterns of disease recurrence after liver resection/ablation for SCC liver metastases and factors associated with recurrence-free survival (RFS) and overall survival (OS). METHOD: Members of the European-African Hepato-Pancreato-Biliary Association were invited to include all consecutive patients undergoing liver resection/ablation for SCC liver metastases between 2002 and 2019. Patient, tumour and perioperative characteristics were analysed with regard to RFS and OS. RESULTS: Among the 102 patients included from 24 European centres, 56 patients had anal cancer, and 46 patients had SCC from other origin. RFS in patients with anal cancer and non-anal cancer was 16 and 9 months, respectively (P = 0.134). A positive resection margin significantly influenced RFS for both anal cancer and non-anal cancer liver metastases (hazard ratio 6.82, 95 per cent c.i. 2.40 to 19.35, for the entire cohort). Median survival duration and 5-year OS rate among patients with anal cancer and non-anal cancer were 50 months and 45 per cent and 21 months and 25 per cent, respectively. For the entire cohort, only non-radical resection was associated with worse overall survival (hazard ratio 3.21, 95 per cent c.i. 1.24 to 8.30). CONCLUSION: Liver resection/ablation of liver metastases from SCC can result in long-term survival. Survival was superior in treated patients with liver metastases from anal versus non-anal cancer. A negative resection margin is paramount for acceptable outcome.

Obstructive jaundice due to a textiloma mimicking a common bile duct stone.

A foreign body is a rare cause of obstructive jaundice. We report a 19-year-old woman with jaundice caused by a surgical gauze in the common bile duct (CBD). Four yours earlier, she had undergone a cholecystectomy and drainage for hydatid disease of the liver. Her postoperative course was complicated by a biliary fistula that healed after 50 days. She now presented with obstructive jaundice of 2 weeks' duration. Magnetic resonance cholangiopancreatography (MRCP) showed a signal-void mass, consistent with a CBD stone. Surgical exploration of the CBD revealed a surgical gauze as the cause of the obstruction. To the best of our knowledge, this is the first case of a surgical gauze obstructing the CBD requiring surgical removal.

Strong coupling of nonlinear electronic and biological oscillators: reaching the "amplitude death" regime.

Interaction between an electronic and a biological circuit has been investigated for a pair of electrically connected nonlinear oscillators, with a spontaneously oscillating olivary neuron as the single-cell biological element. By varying the coupling strength between the oscillators, we observe a range of behaviors predicted by model calculations, including a reversible low-energy dissipation "amplitude death" where the oscillations in the coupled system cease entirely.

Endolumenal ultrasonography in the diagnosis of pancreatic diseases.

We evaluated the usefulness and limitations of endoscopic ultrasonography (EUS) in pancreatic mass lesions. EUS was useful in detecting small pancreatic mass lesions, especially ductal adenocarcinomas smaller than 20 mm and small islet cell tumors smaller than 10 mm. In some of these cases, characteristic echo patterns were specific and useful for differential diagnosis from focal pancreatitis. However, when EUS did not clearly delineate a tumor at the stenotic area of the main pancreatic duct, transpapillary pancreatoscopy and biopsy/cytology were sometimes effective to obtain a definitive diagnosis. EUS fine-needle aspiration should be performed in conjunction with imaging modalities when the differential diagnosis of a pancreatic mass is difficult to make. Although the value of EUS in cancer staging was overestimated, EUS in conjunction with spiral computed tomography or magnetic resonance imaging should be performed for such a purpose. Usefulness and limitations of intraductal ultrasonography (IDUS) also were evaluated. IDUS was useful in detecting carcinoma in situ and small tumors and in assessing parenchymal invasion and the intraductal spread of the tumor. IDUS was also useful in accurately localizing islet cell tumor and in differentiating benign from malignant cases of localized stenosis of the main pancreatic duct. Thus, EUS and IDUS are indispensable modalities in the diagnosis of pancreatic diseases.

Evaluation of various imaging methods in the differential diagnosis of intraductal papillary-mucinous tumor (IPMT) of the pancreas.

BACKGROUND/AIMS: IPMT (intraductal papillary-mucinous tumor) of the pancreas has unique clinicopathological characteristics. The lesions which show characteristic clinical features of IPMT exhibit a wide spectrum of histological types ranging from atypical hyperplasia to invasive cancer. Therefore, surgical treatment cannot be recommended for all patients with IPMT. It is necessary to assess the malignant potential of IPMT in individual patients in order to select an appropriate approach. The aim of this study was to evaluate the effectiveness of endoscopic ultrasonography and intraductal ultrasonography as compared with ultrasonography and computed tomography for this purpose. METHODOLOGY: Ultrasonography, computed tomography, endoscopic ultrasonography and intraductal ultrasonography were performed in 49 cases of IPMT (atypical hyperplasia 7, adenoma 23, noninvasive 7 and invasive adenocarcinoma 12). On the basis of the histopathological analysis of another 28 cases of resected IPMT specimens, criteria for differential diagnosis by imaging modalities were defined as follows: Nonneoplastic lesion (atypical hyperplasia): no wall thickening or nodule; noninvasive IPMT (adenoma and intraductal carcinoma): a nodule or wall thickening is present; and invasive IPMT with pancreatic parenchymal invasion: a mass with a heterogenous pattern or interruption of the pancreatic duct wall by the mass. RESULTS: The diagnostic accuracy rate for differentiating nonneoplastic lesion noninvasive IPMT, and invasive IPMT was 33% by ultrasonography, 38% by computed tomography, 77% by endoscopic ultrasonography, and 67% by intraductal ultrasonography. Sensitivity, specificity and accuracy rates for differentiating neoplastic and nonneoplastic IPMT by ultrasonography was 33%, 100%, 42%, by computed tomography 36%, 100%, 44%, by endoscopic ultrasonography 90%, 71%, 88%, by intraductal ultrasonography 94%, 29%, 84%, respectively. Sensitivity, specificity and accuracy rates for differentiating invasive and noninvasive IPMT by ultrasonography was 25%, 100%, 80%, by computed tomography 33%, 100%, 83%, by endoscopic ultrasonography 55%, 97%, 88%, by intraductal ultrasonography 56%, 91%, 84%, respectively. Diagnostic accuracy for invasive IPMT except minimally invasive cases by endoscopic ultrasonography and intraductal ultrasonography was 80%, based on the results of the examination which demonstrated a higher grade lesion. CONCLUSIONS: With these criteria, ultrasonography and computed tomography showed high specificity, but low sensitivity for the differential diagnosis of neoplastic/nonneoplastic and invasive/noninvasive IPMT. However, endoscopic ultrasonography and intraductal ultrasonography had high sensitivity and diagnostic accuracy for the differential diagnosis of neoplastic/nonneoplastic lesions. Combination of endoscopic ultrasonography and intraductal ultrasonography showed a high accuracy rate in the diagnosis of invasive IPMT. Thus endoscopic ultrasonography and intraductal ultrasonography contributed significantly to the choice of the treatment for IPMT.

Solitary pancreatic tuberculosis mimicking advanced pancreatic carcinoma.

A 40-year-old woman was referred for pancreatic head carcinoma invading the portal vein. The dichotomy between the radiological findings and the general condition of the patient, as well as the laboratory results (no evidence of cholestasis), cast doubt on the diagnosis. There was no history of tuberculosis. The chest radiograph revealed no pathological findings. The anatomic relationships of the lesion entailed a high risk of vascular injury if tissue biopsy were to be done; therefore, diagnostic laparotomy was performed. Biopsy revealed granulomas with caseous necrosis, consistent with tuberculosis. After 6 months of antituberculosis treatment, the lesions had completely resolved. Tuberculosis should be considered in the differential diagnosis of pancreatic masses, particularly in regions where the disease is endemic. The condition usually resembles an advanced pancreatic tumor. Performing a biopsy of inoperable lesions and maintaining a reasonable skepticism in regard to the evaluation of operable lesions (attention to nonexclusive but helpful clues, such as young patient age, history of tuberculosis, absence of jaundice) will lead to the diagnosis in most patients. Diagnostic laparotomy may be required in a small subset of patients. The response to antituberculosis treatment is very favorable. The role of resection (e.g., pancreatoduodenectomy) is very limited.

Vena cava stenting and portorenal shunt in Budd-Chiari syndrome: combination of the 'modern' and the 'classical'.

We have treated a 33-year-old Budd-Chiari patient (due to antiphospholipid syndrome) with a history of myocardial infarction by placing a vascular stent in the inferior vena cava and performing a portorenal shunt with three objectives: (1) to perform a shunt operation on a Budd-Chiari patient with good hepatic functional reserve, (2) to avoid a thoracotomy and manipulation of the heart in a patient with a cardiac thrombus and a history of myocardial infarction and (3) to avoid a synthetic graft in a patient with antiphospholipid syndrome. Vena cava stenting and portorenal shunt make a useful combination which should be included in the armamentarium of the hepatobiliary surgeon.

The transhepatic route for the placement of a duodenojejunal stent: application in a postoperative closed loop obstruction of the duodenum.

A patient who had undergone gastric resection for carcinoma, had closed loop obstruction of the duodenum due to neoplasia at the duodenojejunal junction. The obstruction was relieved successfully by transhepatic placement of a duodenojejunal stent. We were compelled to use the transhepatic route because a Roux-Y reconstruction had been performed. Transhepatic placement may be the only chance of palliation in a small subset of patients with malignant intestinal obstruction.

Long-term results of surgery for liver hemangiomas.

BACKGROUND: Elective surgery for liver hemangiomas is still controversial. HYPOTHESIS: Long-term results show that elective surgery for liver hemangiomas is safe and effective. SETTING: A tertiary care university hospital in Istanbul, Turkey. PATIENTS: Forty-two patients underwent surgery for liver hemangiomas between January 1988 and December 1998; 41 were symptomatic. The primary indications for surgery were abdominal pain in 33 patients, diagnostic uncertainty in 6, and enlargement in 3. The median largest dimension of the major lesion was 10 cm (range, 7-45 cm). MAIN OUTCOME MEASURES: (1) Patients' assessment of the effects of surgery on preoperative symptoms, (2) determination of whether any other pathological conditions were missed in the preoperative evaluation, (3) operative mortality and morbidity, and (4) recurrences. DESIGN: Retrospective cohort study. RESULTS: Enucleation was the most frequent operation (33 patients). Hospital mortality and morbidity were 2.4% (bleeding from the biopsy site on a lesion evaluated as inoperable at laparotomy; 1 patient) and 12% (5 patients), respectively. Thirty-three patients could be followed up for a median of 53 months (range, 6-135 months). Of the 32 preoperatively symptomatic patients, surgery was successful in symptom control in 28 (88%) (complete resolution or significant amelioration). No other cause of pain could be identified during follow-up in the other patients. Control ultrasonography revealed no recurrences. CONCLUSIONS: Elective surgery is indicated in a small subset of patients with hemangiomas because of abdominal pain, enlargement, and diagnostic uncertainty. The results of surgery in symptom control are gratifying in approximately 90% of patients. Recurrences are rare. Enucleation can be performed rapidly and safely in most patients and should be preferred to resection.

Mesoatrial shunt in Budd-Chiari syndrome.

BACKGROUND: The operations with proven effects on survival in Budd-Chiari syndrome are shunt operations and liver transplantation. PATIENTS AND METHODS: Between 1993 and 1999 (June), 13 cases of Budd-Chiari syndrome have been treated surgically. Four cases had concomitant thrombosis of the inferior vena cava; the others had marked narrowing of the lumen due to the enlarged caudate lobe. Mesoatrial (n = 12) or mesosuperior vena caval (n = 1) shunts were constructed with ringed polytetrafluoroethylene grafts. RESULTS: The median portal pressure fell from 45 (range 32 to 55) to 20 (range 11 to 27) cm H(2)O (P <0.001). Two patients died in the early postoperative period. One patient who did not comply with anticoagulant treatment had a shunt thrombosis in the second postoperative year. The other 10 patients are alive without problems during a median 42 (range 1 to 76) months of follow-up. CONCLUSION: Mesoatrial shunt with a ringed polytetrafluoroethylene graft is effective in Budd-Chiari syndrome cases with thrombosis or significant stenosis in the inferior vena cava.

Hepatic alveolar echinococcosis: MRI findings.

The purpose of this study was to describe the magnetic resonance imaging (MRI) appearance of hepatic alveolar echinococcosis (HAE) on T(1)-weighted, T(2)-weighted and postgadolinium images. A total of 13 lesions were demonstrated in 13 patients. All patients underwent MR examination at 1 T imager. MR examinations included precontrast T(1)-weighted breathing averaged spin echo (SE), breath-hold spoiled gradient echo, T(2)-weighted TSE sequences with and without fat suppression, and T(1)-weighted breath-hold spoiled gradient echo (SGE) sequence following i.v. after gadolinium administration. All lesions were confirmed with histopathology. HAE hepatic lesions revealed geographic patterns of variable signal intensities on noncontrast T(1)- and T(2)-weighted images. Slightly hyperintense, iso- and hypointense signal on T(1)-weighted images corresponded to calcified regions, which appeared hypo-isointense signal on T(2)-weighted images. Necrotic areas were hypointense signal on T(1)-weighted and hyperintense signal on T(2)-weighted images. On postgadolinium images, lesions did not reveal enhancement. Dilatation of intrahepatic bile ducts distal to HAE abscesses were observed in five patients and portal vein invasion or compression was observed in four patients, lobar atrophy of the liver was coexistent finding in cases with portal vein compression. The MRI appearance of HAE abscesses included large irregularly marginated masses with heterogenous signal on T(1)- and T(2)-weighted images and lack of enhancement with gadolinium.

Primary lymphoma of the liver: report of a case.

We describe herein a female patient with non-Hodgkin's lymphoma of the liver and present a review of the related literature. The patient was referred with the diagnosis of malignant hemangiopericytoma (with an open biopsy). The physical examination, standard laboratory test results and tumor marker levels were all normal. A nonstandard left lobectomy was performed. Histopathological and immunohistochemical examinations revealed non-Hodgkin's lymphoma of B-cell type. The findings of a peripheral blood smear and bone marrow biopsy were normal. There was no other site of involvement based on physical or radiological examinations. These findings established the diagnosis of primary hepatic lymphoma. Fewer than 100 cases have been reported in the world literature. The best treatment results have been obtained by a resection followed by chemotherapy when feasible.

Pancreatobiliary adenosquamous carcinoma (report of two cases).

Adenosquamous carcinomas are rare malignant tumors of the pancreas and periampullary region. We present two cases of pancreatic and periampullary adenosquamous carcinoma with clinicopathologic, histo- and immunohistochemical findings. A 51-year-old and a 48-year-old man presented with right upper quadrant pain of three months duration and jaundice for two weeks. Both cases had an elevation of liver enzymes and CA 19-9. In the first case, computerized tomography showed a 3 cm-mass at the pancreatic head. In the second one, endoscopic retrograde choledocopancreatography (ERCP) revealed a mass at the ampulla Vateri localization. A pancreatoduodenectomy was performed for both cases. Gross pathologic examination displayed a solid, gray-white colored 4 cm-tumor at the pancreatic head and a solid, pink-white colored, 2 cm-tumor at the periampullary region bulging into the duodenal lumen. Microscopically, both tumors were composed of solid nests of squamous cells with pearl formation and mucin-containing glandular cells and diagnoses were adenosquamous carcinoma. Furthermore, histo- and immunohistochemical findings were consistent with microscopic diagnoses.

Phantom steatosis of the liver: report of a case.

A patient, referred under a diagnosis of metastatic liver tumors, was found to have multiple areas of focal fatty change (FFC) which, during follow-up, exhibited discordant evolutions. To our knowledge, this phenomenon-regression of a FFC lesion with concurrent appearance or progression of other similar lesions in the same patient, has been reported in only one previous case. FFC can be strongly suggested by clinical, biochemical and radiologic criteria. However, an exact diagnosis can only be made with biopsy. To avoid misdiagnosing a malignancy as FFC and vice versa, biopsy should be performed without hesitation in all patients in whom a change in approach is possible.

Elective repair of abdominal wall hernias in decompensated cirrhosis.

BACKGROUND/AIMS: Abdominal wall hernia is a common feature of decompensated cirrhosis. However, literature on elective hernia repair in these patients is limited. Here we report the experience of our center. METHODOLOGY: Eleven hernias (seven umbilical, three inguinal and one incisional) in nine patients with decompensated cirrhosis were repaired. The indication for operation was repeated incarceration in two patients and significant pain in four; three patients with umbilical hernias had ulceration and necrosis of the overlying skin. Pre-operatively, medical therapy of ascites was conducted at the hepatology unit. Umbilical hernias were treated with the classic Mayo repair; in all cases but two, this was buttressed with a prolene graft. One inguinal hernia was repaired with the plication-darn technique; the other two and the incisional hernia were repaired with prolene grafts. RESULTS: There was no mortality. One patient had a scrotal hematoma; two patients had leakage of ascites into the wound. Seven patients were followed up. Four patients died without recurrence after a median period of 12 months (range 6-22). The other patients have no recurrence at 1, 10 and 40 months post-operatively. CONCLUSIONS: Umbilical and inguinal hernias in patients with decompensated cirrhosis may be repaired safely on an elective basis. Control of ascites is vital for success.

Laparoscopic treatment of hepatic hydatid disease.

Surgery is still the main modality in the treatment of hepatic hydatid disease. Laparoscopic methods, with their low morbidity, have gained prominence in many fields and, in some cases, have nearly replaced open surgery. In this report, a laparoscopic method for the treatment of hepatic hydatid disease is described and the results in the first six cases are presented. The method involves the use of an aspirator-grinder apparatus designed specifically for laparoscopic surgery. The postoperative courses of the patients were very comfortable and no complication related to the laparoscopic technique occurred. The method achieves evacuation of all viable cyst contents with the patient benefits of laparoscopic surgery. The apparatus practically eliminates the risk of spillage. The postoperative parameters and the early follow-up results (21-27 months) are very encouraging.

Laparoscopic surgery of hepatic hydatid disease: initial results and early follow-up of 16 patients.

Surgery is the main modality in the treatment of hepatic hydatid disease. In this report, a laparoscopic surgical method is described, and the results in the first 16 cases are presented. The method involves the use of an aspirator-grinder apparatus that achieves effective evacuation of viable cyst contents with the patient benefiting from the laparoscopic approach. Cavity infection occurred in two patients and was treated conservatively. In another patient, postoperative ultrasonography revealed a thick-walled cavity containing a dense fluid. Because the patient was symptomatic, pericystectomy was performed during the sixth postoperative month. Early postoperative parameters and the early follow-up results in other patients (2-17 months) are encouraging. The method is particularly suitable for uncomplicated, early-stage cysts located in laparoscopically accessible locations.