Role of Stereotactic Body Radiation Therapy in Portal Vein Tumor Thrombosis in Hepatocellular Carcinoma: A Prospective Single Institute Experience

PURPOSE/OBJECTIVE(S)

Patients diagnosed with Hepatocellular carcinoma (HCC) complicated with portal vein tumor thrombosis (PVTT) have a limited number of treatment options available and are associated with an overall poor prognosis. With the recent developments in the field of radiation therapy, the role of radiotherapy particularly Stereotactic Body radiotherapy (SBRT) has increased as a loco-regional therapy for HCC. This study was planned to evaluate the role of SBRT in Locally advanced HCC complicated with PVTT and its role as loco-regional therapy.

MATERIALS/METHODS

We conducted a prospective study that included patients diagnosed with HCC complicated with PVTT Child-Turcotte Pugh (CTP) Class A/B with a maximum score of 7, diagnosed on triple phase Contrast-Enhanced - MRI unsuitable for other ablative procedures. Patients with Bilirubin levels > 4 mg/dl, active Hepatitis, CTP score >7, normal liver volume <700cc or history of prior radiotherapy were excluded from the study. Patients underwent a contrast enhanced 4D-CT simulation with abdominal compression and were planned for SBRT using VMAT technique. Patients were followed-up as per Institute protocol. CECT or MRI for a radiological response was done for response assessment using mRECIST criteria version 1.1. A baseline MRI was done at one-month post-SBRT to understand any RT changes in the liver and to differentiate from tumor progression during the response assessment at three months.

RESULTS

A total of 22 patients with HCC were recruited and received SBRT to PVTT, with a dosage between 30-42 Gy over 6 fractions treated on alternate days. Patients were assessed post-treatment with triphasic CE-MRI every 3 months as per institute protocol. Five patients had achieved Complete response in form of Portal vein recanalization. Three patients had Partial response to the treatment. Seven patients maintained stable disease status whereas six patients had disease progression during the entire course of treatment. The response rate (CR+PR) to treatment was 36.3% at the time of analysis. The Overall Response rate (CR+PR+SD) was 69%. No grade 3 or 4 toxicities were observed and treatment was tolerated well by patients. Kaplan-Meier method was applied to calculate the survival probability at various follow-up intervals. The median time for overall survival was 25 months ((95% CI: 15-35). Out of the 22 subjects included in the study, 6 patients died. There was a 78% survival probability at 12 months and a 68% survival probability at 18 months of follow-up.

CONCLUSION

This prospective single-arm study demonstrated the vital role of SBRT in the treatment of Hepatocellular carcinoma with Portal vein tumor thrombosis and its efficacy in terms of achieving excellent local control with relatively lesser toxicities compared with existing treatment modalities. Patients have shown benefit post-treatment in terms of thrombus reduction and restoration of Portal vein flow making them suitable for further treatment like Resection or TACE.

Biological Response Assessment in Hepatocellular Carcinoma Post Stereotactic Body Radiotherapy

PURPOSE/OBJECTIVE(S)

Biological Response in Hepatocellular carcinoma (HCC) is measured in terms of serum alpha-fetoprotein (AFP) which is elevated in nearly 60% HCC patients at baseline and is directly related to the severity of the disease. This biological response is defined as the reduction of more than 50% from the baseline levels and is associated with an increased percentage of tumor necrosis and is directly related to increased loco-regional control. Patients diagnosed with HCC have very limited treatment modalities. With the recent advances in the field of radiation therapy and the development of Stereotactic Body radiotherapy (SBRT), the role of radiotherapy has increased as a loco-regional modality for HCC. In this single-arm prospective study, we evaluated the biological response post-SBRT in patients diagnosed with HCC.

MATERIALS/METHODS

We conducted a prospective study that included patients diagnosed with HCC with baseline elevation of serum AFP, Child-Turcotte Pugh (CTP) Class A/B with a maximum score of 7. Patient's serum AFP levels were recorded at baseline, pre-treatment, and post-treatment. The biological response was measured at 3 months post-treatment and compared with the baseline serum AFP levels using Wilcoxon signed rank test.

RESULTS

A total of 14 patients with HCC were recruited and received SBRT to the target lesion, with a dose between 30-42 Gy over 6 fractions treated on alternate days. Patients were assessed post-treatment at one month with triphasic CEMRI and serum AFP levels. 12 out of 14 patients (85.71%) had a biological response at 3 months follow-up and levels showed further decline unless a progression was found. The median (IQR) serum AFP level was 1131 ng/ml (359-5668 ng/ml) at baseline. Post-treatment serum AFP levels had a median (IQR) value of 156 ng/ml (15-372 ng/ml) showing a near reduction of 86% from baseline, which was significant. 2/14 pts (14.28%) showed no reduction or even increase in serum AFP levels post-treatment.

CONCLUSION

This prospective single-arm study demonstrated the vital role of SBRT in the treatment of HCC and its importance in achieving a better disease control. The response was achieved in 86% of patients with marked reduction of nearly 90% in serum AFP levels as compared to the baseline and increased median OS and PFS as compared to patients not receiving radiotherapy. Further prospective studies are warranted to confirm our findings.

Correlation between MRI and hip arthroscopy in children with Legg-Calve-Perthes disease

BACKGROUND

Most of the information available about Legg-Calve-Perthes disease (LCPD) at present is gained through imaging modalities including plain radiographs and magnetic resonance imaging (MRI). But the accuracy of MRI in this disease and its predictive value to reveal various intra-articular pathologies is not known. We correlated the findings of MRI with those seen on hip arthroscopy in children with active stage of LCPD.

METHODS

We conducted a prospective observational study in which MRI findings were correlated with corresponding findings on hip arthroscopy in a cohort of 25 patients of active LCPD below 12 years of age. The parameters noted on MRI included status of ligamentum teres, status of the labrum, synovial effusion if any, condition of the femoral and acetabular articular cartilage including chondral flaps, chondral indentation and intra-articular loose bodies. The indication of performing hip arthroscopy was persistent severe hip pain (Wong-Baker FACES pain scale ≥ 3) after 6 months of conservative management. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for MRI considering arthroscopy as a gold standard.

RESULTS

Synovial effusion was seen in a large number of patients on both MRI (17) and hip arthroscopy (24). The sensitivity (95% confidence interval) of MRI was found to be low, especially with respect to labral tears [25% (0.63-80.6)] and intra-articular loose bodies [20% (0.51-71.6)]. NPV for synovial effusion was also found to be low [12.5% (0.32-52.7)], although specificity and PPV of MRI were found to be good for all the parameters.

CONCLUSIONS

MRI cannot be completely relied upon for identifying all the intra-articular pathologies in children with LCPD, although it has a good complimentary role. In patients with severe persistent pain with suspicion for joint changes, hip arthroscopy can provide a safe and efficient procedure (better than MRI) for eliciting the associated joint pathology.

Transcript profiling of genes expressed during fibre development in diploid cotton (Gossypium arboreum L.)

Background

Cotton fibre is a single cell and it is one of the best platforms for unraveling the genes express during various stages of fibre development. There are reports devoted to comparative transcriptome study on fiber cell initiation and elongation in tetraploid cultivated cotton. However, in the present investigation, comparative transcriptome study was made in diploid cultivated cotton using isogenic fuzzy-lintless (Fl) and normal fuzzy linted (FL) lines belong to Gossypium arboreum, diploid species at two stages, 0 and 10 dpa (days post anthesis), using Affymetrix cotton GeneChip genome array.

Result

Scanning electron microscopy (SEM) analysis uncovered the occurrence of few fibre cell initials in the Fl line as compared to many in Normal FL at −2 and 0 dpa. However, at 10 dpa there were no fibre cells found elongated in Fl but many elongated cells were found in FL line. Up-regulation of transcription factors, AP2-EREBP, C2H2, C3H, HB and WRKY was observed at 0 dpa whereas in 10 dpa transcription factors, AP2-EREBP, AUX/IAA, bHLH, C2H2, C3H, HB, MYB, NAC, Orphans, PLATZ and WRKY were found down regulated in Fl line. These transcription factors were mainly involved in metabolic pathways such as phytohormone signaling, energy metabolism of cell, fatty acid metabolism, secondary metabolism and other signaling pathways and are related directly or indirectly in fiber development. Quantitative real-time PCR was performed to check fold up or down-regulation of these genes and transcription factors (TFs) down regulated in mutants as compared to normal at 0 and 10 dpa.

Conclusion

This study elucidates that the up-regulation of transcription factors like AP2-EREBP, C2H2, C3H, HB, WRKY and phytohormone signaling genes at 0 dpa and their down-regulation at the 10 dpa might have constrain the fibre elongation in fuzzy-lintless line. Along with this the down-regulation of genes involved in synthesis of VLCFA chain, transcripts necessary for energy and cell wall metabolism, EXPANSINs, arabinogalactan proteins (AGPs), tubulin might also be the probable reason for reduced growth of fibres in the Fl. Plant receptor-like kinases (RLKs), Leucine Rich Repeats) LRR- family protein and signal transduction coding for mitogen-activated protein kinase (MAPK) cascade, have been engaged in coordination of cell elongation and SCW biosynthesis, down-regulation of these might loss the function leads to reduced fibre growth.

Electronic supplementary material

The online version of this article (doi:10.1186/s12864-017-4066-y) contains supplementary material, which is available to authorized users.

Evolving management of insulinoma: Experience at a tertiary care centre

BACKGROUND & OBJECTIVES

Since our previous study in 2006, several new modalities for localization of cause of endogenous hyperinsulinemic hypoglycaemia such as multiphasic computed tomography (CT), multiphasic magnetic resonance imaging (MRI), endoscopic ultrasound (EUS), intraoperative ultrasound, and intra-arterial calcium infusion with arterial stimulation venous sampling (ASVS) have become available. Therefore, to evaluate the relative usefulness of various imaging modalities to guide future management in terms of diagnosis and patient care, we analyzed presentation and management of patients of endogenous hyperinsulinemic hypoglycaemia.

METHODS

In this retrospective study, medical records of patients admitted with endogenous hyperinsulinemic hypoglycaemia were retrieved. Data pertaining to clinical features, diagnosis, imaging, surgery and patient outcome were extracted. The localization of insulinoma by preoperative imaging techniques was compared with the findings at surgery to assess the accuracy of localization.

RESULTS

Fasting hypoglycaemia was present in all, and post-prandial hypoglycaemia (plasma glucose ≤50 mg/dl within four hours of meal) in 25.8 per cent. Mean duration of symptoms before reaching a diagnosis of hyperinsulinemic hypoglycaemia was 3.9 years. Mean duration of provocative fast was 21.8 h (range 6-48 h). Among the currently used imaging modalities, the sensitivity of localizing tumour was 79.3 per cent for multiphasic CT, 85 per cent for multiphasic MRI and 95 per cent for EUS. EUS detected tumour missed by both CT and MRI. All, except one of the operated patients, were cured by surgery.

INTERPRETATION & CONCLUSIONS

Our results suggest that patients with insulinoma have a varied presentation. Multiphasic contrast-enhanced MRI/CT scan, EUS and ASVS may be complimentary in pre-operative localization.

Minimally invasive image-guided interventional management of Haemobilia

Hemobilia is a well known cause for upper gastrointestinal (UGI) bleed seen commonly in setting of iatrogenic or accidental trauma and various inflammatory and neoplastic conditions. Patients present with UGI bleed and symptoms of associated biliary obstruction. Management options in intractable cases are surgery and endovascular embolisation. We report a series of eighteen patients presented with severe hemobilia from January 2010 to October 2014, who were managed by endovascular approach in our department. Etiology in these patients were trauma (n = 3), liver biopsy (n = 3), surgery (n = 3), percutaneous procedures (n = 2), inflammatory (n-3), neoplasm (n = 1) and the rest were idiopathic. Angiography revealed pseudoaneurysms of hepatic artery (n = 5), splenic artery (n = 1) and gastroduodenal artery (n = 1) and arterio-biliary fistula (n = 1). Embolising agents used were detachable coils (n = 10) and glue (n = 8). All patients had technical and clinical success with minor non-consequential complications. Our findings show that endovascular embolisation is a simple, safe, accurate and effective treatment in patients with severe hemobilia. It is a viable alternative to major and potentially morbid surgeries.

Genome-wide transcriptomic and proteomic analyses of bollworm-infested developing cotton bolls revealed the genes and pathways involved in the insect pest defence mechanism

Cotton bollworm, Helicoverpa armigera, is a major insect pest that feeds on cotton bolls causing extensive damage leading to crop and productivity loss. In spite of such a major impact, cotton plant response to bollworm infection is yet to be witnessed. In this context, we have studied the genome-wide response of cotton bolls infested with bollworm using transcriptomic and proteomic approaches. Further, we have validated this data using semi-quantitative real-time PCR. Comparative analyses have revealed that 39% of the transcriptome and 35% of the proteome were differentially regulated during bollworm infestation. Around 36% of significantly regulated transcripts and 45% of differentially expressed proteins were found to be involved in signalling followed by redox regulation. Further analysis showed that defence-related stress hormones and their lipid precursors, transcription factors, signalling molecules, etc. were stimulated, whereas the growth-related counterparts were suppressed during bollworm infestation. Around 26% of the significantly up-regulated proteins were defence molecules, while >50% of the significantly down-regulated were related to photosynthesis and growth. Interestingly, the biosynthesis genes for synergistically regulated jasmonate, ethylene and suppressors of the antagonistic factor salicylate were found to be up-regulated, suggesting a choice among stress-responsive phytohormone regulation. Manual curation of the enzymes and TFs highlighted the components of retrograde signalling pathways. Our data suggest that a selective regulatory mechanism directs the reallocation of metabolic resources favouring defence over growth under bollworm infestation and these insights could be exploited to develop bollworm-resistant cotton varieties.

Current Status of Percutaneous Transhepatic Biliary Drainage in Palliation of Malignant Obstructive Jaundice: A Review

Malignancies leading to obstructive jaundice present too late to perform surgery with a curative intent. Due to inexorably progressing hyperbilirubinemia with its consequent deleterious effects, drainage needs to established even in advanced cases. Percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde cholangiopancreatography (ERCP) are widely used palliative procedures each with its own merits and lacunae. With the current state-of-the-art PTBD technique consequent upon procedural and hardware improvement, it is equaling ERCP regarding technical success and complications. In addition, there is a reduction in immediate procedure-related mortality with proven survival benefit. Nonetheless, it is the only imminent lifesaving procedure in cholangitis and sepsis.

Endovascular embolization of pseudoaneurysm of left colic artery developing after renal biopsy

Vascular complications after percutaneous renal biopsy are uncommon and may require interventional management. In most of these cases, the pathology is a renal arterial pseudoaneurysm (PsA) or an arterio-venous fistula. Injury to other vessels like aorta, lumbar arteries or mesenteric arteries is rare with only one case of left colic artery PsA reported in literature. We report a case of a 60-year-old female, who developed left colic artery PsA after renal biopsy, which was successfully embolized through endovascular route using microcoils.

Radiological interventions in HVOTO--practical tips

Hepatic venous outflow tract obstruction (HVOTO) comprises of constellation of disorders causing obstruction of hepatic venous outflow or suprahepatic inferior vena cava (IVC) or both and leading to increased hepatic sinusoidal pressure and portal hypertension. Clinical presentation in HVOTO includes both acute onset or chronic insidious onset of the disease and predominant clinical manifestations consist of ascites, hepatomegaly, and portal hypertension. IVC/hepatic vein (HV) web or thrombosed hepatic veins replaced by fibrotic constriction or thrombus in suprahepatic IVC is encountered as the pathogenic process at such obstructions. Due to advances in radiologic techniques there has been a changes in the management protocol of HVOTO with surgery or liver transplantation reserved for patients not suitable for radiological interventions or requiring liver transplantation. The present article reviews the techniques of various radiological interventions in HVOTO and their efficacy.

A rare case of combined soft-tissue and intraosseous arteriovenous malformation of the hand with diffuse periosteal elevation: imaging appearances

Arteriovenous malformations are uncommon congenital lesions of the hand. Although present at birth, they usually manifest later in life. Ultrasonography, MRI and digital subtraction angiography play an important role in the diagnosis of these lesions. We report the imaging appearances of an unusual case of combined soft-tissue and intraosseous arteriovenous malformation (AVM) of the hand with marked periosteal elevation in a 12-year-old child. Although associated skeletal changes are common, diffuse periosteal elevation owing to direct communication of the AVM with the subperiosteal space has not, to the best of our knowledge, been reported previously.

Radiographical approach to jaw lesions

Many lesions that occur in the jaw have a similar radiographical appearance and it is often difficult to differentiate among them. Despite development of various cross-sectional imaging modalities, the radiograph still remains the first and the most important investigation. Radiographical evaluation of jaw lesion characteristics, which include location, margin, density, relation to tooth, along with knowledge of the clinical data, generally helps in narrowing the differential diagnosis.

Imaging findings of congenital tuberculosis in three infants

Congenital tuberculosis is a rare entity and diagnosis is usually delayed due to the nonspecific nature of the signs and symptoms. Imaging studies facilitate the early diagnosis of the disease and institution of appropriate therapy. We describe three cases of congenital tuberculosis along with the imaging features. Imaging findings of the chest included multiple pulmonary nodules, consolidation with cavitation, extensive bronchopneumonia and necrotic mediastinal adenopathy. Abdominal imaging findings included hepatomegaly with or without splenomegaly, multiple focal lesions in the spleen and retroperitoneal lymphadenopathy.

Invasive sinus aspergillosis with perineural spread in an immunocompetent patient

Invasive aspergillosis of paranasal sinuses is usually seen in immunocompromised patients and is associated with a very high mortality rate. The disease is distinctly uncommon in immunocompetent patients. A rare case of invasive aspergillosis of paranasal sinus and orbit with intracranial extradural extension via perineural spread along the maxillary division of the trigeminal nerve in an immunocompetent patient is presented.

Primary breast tuberculosis masquerading as carcinoma

Although tuberculosis is a very common disease in endemic areas, isolated involvement of the breast is very rare. Any form of tuberculous mastitis may present with features of malignancy. Diagnosis is mainly based on identification of tubercle bacilli. We report a 50-year-old woman with primary tuberculous abscess of the breast which simulated carcinoma on mammography, and describe the importance of ultrasonography in differentiating abscess from malignancy.

Pulmonary infections mimicking cancer: report of four cases

Lung infections infrequently simulate cancer, and their differentiation, based on imaging findings, can sometimes be difficult. The infections may be fungal, mycobacterial, parasitic or, rarely, viral. A biopsy is required to prove the infectious nature of the lesions. A specific diagnosis is necessary for initiation of appropriate therapy. We report four cases of chronic pulmonary infections, which were wrongly diagnosed as bronchogenic carcinoma based on radiological features. We also reviewed the existing literature.

Fibrolipomatous hamartoma of median nerve

Fibrolipomaous hamartoma is a benign neoplasm of nerves, resulting from anomalous growth of fibroadipose tissue of the nerve sheath. The median nerve is the most commonly involved nerve. Magnetic resonance imaging (MRI) features are pathognomonic, showing a coaxial cable-like appearance on axial images and spaghetti-like appearance on coronal images. Preferred management of the lesion is conservative.

Gastric teratoma

Gastric teratoma is a very rare tumour that usually manifests as an abdominal mass, resulting in gastrointestinal bleeding and/or obstructive features. We report gastric teratoma occurring in a two-year-old boy who presented with an abdominal mass. Diagnosis was aided by the classical findings of teratoma on computed tomography, seen as the presence of fat, calcifications, and both solid and cystic areas.

Radiological evaluation of covered self-expandable metallic stents used for palliation in patients with malignant esophageal strictures

PURPOSE

To study the role of self-expandable metallic stents in malignant esophageal strictures in terms of patency, improved dysphagia score, and possible associated complications.

MATERIAL AND METHODS

Twenty-two patients with inoperable carcinoma of the esophagus underwent stent placement. Four different varieties of covered stents were used. Stenting was performed under fluoroscopic guidance and local pharyngeal anesthesia. During follow-up, patients were examined clinically and radiologically to assess the effectiveness of stents in relieving dysphagia, to check the stent position, patency, and possible complications.

RESULTS

Fluoroscopic placement of the stent was successful and well tolerated in all patients without any serious complications. Accurate stent placement was possible in 95% of cases. The mean dysphagia score prior to stenting was 3.5 and poststent 1.2, with an improvement of 2.3 degrees. In two patients with associated fistulas, complete closure was seen after stent insertion. There was poor stent expansion in three patients. Significant tumor overgrowth occurred in two patients, and a second overlapping stent was deployed in one case. Three patients developed food impaction, which needed endoscopic removal of impacted food in two cases.

CONCLUSION

Fluoroscopic placement of self-expandable metallic stents is a safe and effective method of palliating severe dysphagia and fistulas in patients with inoperable esophageal carcinoma. However, complications such as tumor overgrowth and food impaction may require reintervention after stent placement.

Desmoplastic round cell tumour of the abdomen

Desmoplastic round cell tumour is a very rare tumour of childhood and young adults, and is not usually suspected as an explanation of intraabdominal or pelvic tumour. We report two cases of desmoplastic round cell tumour of the abdomen in the paediatric age group, occurring in two boys, an 11-year-old and a 13-year-old. We aim to demonstrate the imaging findings and to emphasise the importance of including this tumour in the differential diagnosis of childhood intraabdominal and pelvic tumours.

Comparison of graded compression ultrasonography and unenhanced spiral computed tomography in the diagnosis of acute appendicitis

INTRODUCTION

To compare the accuracy of graded compression ultrasonography (US) and unenhanced spiral computed tomography (CT) in the diagnosis of acute appendicitis.

METHODS

This prospective study comprised 58 consecutive patients with high clinical suspicion of acute appendicitis. After careful clinical assessment and laboratory investigations, all the patients were independently evaluated by graded compression US followed by unenhanced spiral CT, in order to establish the diagnosis. CT was performed from the level of the third lumbar vertebral body to the pubic symphysis, and no patient was given oral, rectal or intravenous contrast agents. The results were compared with operative findings and clinical follow-up.

RESULTS

Out of the 58 patients evaluated, surgical confirmation was obtained in 52 patients and the remaining six patients were managed conservatively. Statistical analysis was based on the 52 patients who were surgically confirmed. 48 of the operated patients had evidence of appendicitis and four patients had negative findings. In our study, 90 percent of patients were adults and the following results were more applicable to the adult age group. Analysis of the data for US and CT, respectively, revealed a sensitivity of 67.3 percent versus 95.8 percent, specificity of 100 percent versus 75 percent, accuracy of 71.2 percent versus 90.3 percent, positive predictive value of 100 percent versus 97.8 percent, and negative predictive value of 15.8 percent versus 60 percent. Out of the operated patients, four patients did not have acute appendicitis and alternative diagnosis was suggested by US and CT in one patient. Of the six patients managed conservatively, an alternative diagnosis was reached both by US and CT in two patients.

CONCLUSION

We conclude that unenhanced spiral CT is more sensitive than US in detecting appendicitis, especially in adult patients.