Hand-foot syndrome due to sorafenib in hepatocellular carcinoma treated with vitamin E without dose modification; a preliminary clinical study

PURPOSE

Sorafenib has been found to have significant clinical activity against hepatocellular carcinoma (HCC). Hand-foot skin syndrome (HFS) has been described with the usage of sorafenib. It is a dose-limiting toxicity and may lead to compromised efficacy because of dose reduction.

METHODS

From 14 patients diagnosed with HCC 10 who developed HFS while on treatment with sorafenib were included in this study. Sorafenib was administered orally at a dose of 400 mg twice daily vitamin E usage can be effective in HFS due to sorafenib, therefore vitamin E 300 mg/day was started when HFS occurred. HFS was graded according to the National Cancer Institute (NCI) criteria.

RESULTS

Grade 2-3 HFS was found in 10 of 14 patients. Vitamin E was started to all patients without using topical agents. Mean time to the appearance of HFS was 15 ± 3 days (range 10-22) after starting sorafenib. Grade was 3 in 4 patients, 2 in 4 patients and 1 in 2 patients. Vitamin E administration had a marked effect after 10-12 days of its initiation. Skin lesions disappeared without any dose modification.

CONCLUSION

Sorafenib is the gold standard for HCC treatment. Dose modification due to HFS decreases the effectiveness of this agent. Adding vitamin E to sorafenib is effective in HFS without dose reduction or treatment interruption. This is the first clinical study to report resolution of HFS with vitamin E due to sorafenib therapy.

Y-stent-assisted coil embolization of wide-neck intracranial aneurysms. A single center experience

This report evaluated the short and midterm results of the safety and effectiveness of the treatment technique with hybrid and non-hybrid Y-configured, dual stent-assisted coil embolization of wide-neck intracranial aneurysms, and reviewed the literature concerning this technique. Nine patients, eight with unruptured and one with ruptured aneurysms were included in the study. Of aneurysms embolized with a hybrid (with two different stents) and non-hybrid (with two identical stents) technique, three were located in the anterior communicating artery, three at the tip and one at the distal site of basilar artery, and two in the middle cerebral artery. All aneurysms included the orifices of bifurcation vessels. All aneurysms were stented and embolized during the same session. While Neuroform and Enterprise stents were used in the hybrid technique, two Enterprise stents were used in the non-hybrid technique. Dual Y-stent assisted coil embolization was performed successfully in eight of nine patients (88.9%), including five patients (55.6%) with hybrid and three patients (33.3%) with non-hybrid technique. No procedural complication, no mortality and no minor or major neurological complications were seen during the angiographic or clinical follow-up. When an attempt was made at passing the second stent through the first Enterprise stent, the stent protruded inside the aneurysm in one patient (11.1%). Hybrid or non-hybrid dual Y-stent-assisted coil embolization in the treatment of ruptured or unruptured wide-neck and complex intracranial aneurysms is a safe and effective method from the viewpoint of short and midterm results.

Perfusion and diffusion magnetic resonance imaging in idiopathic intracranial hypertension

OBJECTIVES

Idiopathic intracranial hypertension (IIH) is characterized by abnormal elevation of intracranial pressure without any underlying etiologic factor. Papilledema is the major clinical finding whereas neuroradiological imaging findings are almost always normal. The aim of this preliminary study was to determine if diffusion and perfusion magnetic resonance imaging in patients with IIH might be beneficial in the management of the disease.

MATERIALS AND METHODS

Prospectively, we evaluated standard magnetic resonance, magnetic resonance angiographies and venographies, diffusion and perfusion magnetic resonance findings of 16 patients with IIH and of 16 age-, sex-, and weight-matched normal individuals as a control group. Patients with IIH underwent a detailed neuroophthalmologic examination and lumbar puncture for evaluation of cerebrospinal fluid pressure. Magnetic resonance imaging was performed with 1.5 T equipment.

RESULTS

On physical examination, all patients had characteristic papilledema, varying degrees of headache, blurred vision and tinnitus. Cerebrospinal fluid pressure was higher than 250 mm H2O in all patients. A statistically significant decrease in cerebral blood flow in six patients, whereas insignificant increase in two were detected. Cerebral blood volume values were almost similar to normal control group's values. Significant mean transit time prolongation was found in six patients as well.

CONCLUSIONS

Idiopathic intracranial hypertension is a clinical syndrome which requires prompt diagnosis and a thorough evaluation. Treatment is crucial for preventing visual loss and improving associated symptoms. It is also important to detect cerebral perfusion changes, as cerebrovascular complications may be associated. Although our patient group is small for statistical evaluation, it is a preliminary study using perfusion and diffusion magnetic resonance which may contribute to IIH management.

Determining the level of the dural sac tip: magnetic resonance imaging in an adult population

PURPOSE

To determine the variation in the location of the dural sac (DS) in a living adult population and to correlate this position with age and sex.

MATERIAL AND METHODS

T2-weighted, midline, sagittal, spin-echo magnetic resonance imaging (MRI) studies of 743 patients were assessed to identify the tip of the DS. This location was recorded in relation to the upper, middle, or lower third of the adjacent vertebral body or the adjacent intervertebral disk.

RESULTS

Frequency distribution for levels of termination of the DS on MRI demonstrated that the end of the DS was usually located at the upper one-third of S2 (25.2%). The mean level in females was also the upper one-third of S2 (26.5%) and in males the lower one-third of S2 (24.1%). The overall mean DS position was mostly at the upper one-third of S2. No significant differences in DS position were seen between male and female patients or with increasing age.

CONCLUSION

It is important to know the possible range for the termination level of the DS when performing caudal anesthesia and craniospinal irradiation in some clinical situations. The distribution of DS location in a large adult population was shown to range from the L5-S1 intervertebral disk to the upper third of S3 vertebrae.

Primary and metastatic rhabdomyosarcoma in the breast: report of two pediatric cases

Rhabdomyosarcoma (RMS) is a common childhood malignancy which can rarely be located in the breast. Here, we report two pediatric cases of breast RMS, one primary, the other secondary involvement. Primary one is alveolar, and the other embryonal subtype. Imaging findings with ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI) and a thorough review of literature are presented.

Percutaneous self-expandable uncovered metallic stents in malignant biliary obstruction. Complications, follow-up and reintervention in 154 patients

PURPOSE

Evaluation of technique, complications and the long-term follow-up data of 154 patients with inoperable malignant biliary obstruction who underwent percutaneous placement of metallic stents.

MATERIAL AND METHODS

During a 6-year period, 224 self-expanding metallic stents (150 biliary Wallstents and 74 Memotherm nitinol stents) were inserted in 154 patients with inoperable malignant biliary obstruction. 100 patients had obstructions at the proximal (supracystic) level, and 54 at the distal (infracystic) level. The causes of obstructions were hilar cholangiocarcinoma (n = 64), pancreatic carcinoma (n = 34), gallbladder carcinoma (n = 24), metastatic carcinoma (n = 21), common bile duct carcinoma (n = 8), and hepatocellular carcinoma (n = 3). A complete follow-up was available for all patients.

RESULTS

The 30-day mortality was 9%, with no procedure-related deaths. The clinical success rate within the first 30 days was 88%. The total rate of early, procedure-related complications was 28%, and half of them were due to the percutaneous transhepatic catheter drainage procedure. Recurrent jaundice occurred in 28 (18%) patients and in 23 (82%) of these, reinterventions were made in order to relieve reobstructions. The mean length of survival for the entire patient group was 4 months, while the mean period of patency for all stents was 6 months. We found no statistically significant difference in patient survival or stent patency periods in regard to the level and cause of obstruction.

CONCLUSION

Percutaneous metallic stent placement maintains equal palliation in patients with proximal and distal malignant biliary obstructions caused by any tumor type. Most of the early complications were due to procedures performed before stent insertion and could be decreased by direct stent insertions. The most common late complication, reobstruction, is inevitable but can be easily treated in the majority of patients.

Percutaneous self-expandable uncovered metallic stents in malignant biliary obstruction. Complications, follow-up and reintervention in 154 patients

PURPOSE

Evaluation of technique, complications and the long-term follow-up data of 154 patients with inoperable malignant biliary obstruction who underwent percutaneous placement of metallic stents.

MATERIAL AND METHODS

During a 6-year period, 224 self-expanding metallic stents (150 biliary Wallstents and 74 Memotherm nitinol stents) were inserted in 154 patients with inoperable malignant biliary obstruction. 100 patients had obstructions at the proximal (supracystic) level, and 54 at the distal (infracystic) level. The causes of obstructions were hilar cholangiocarcinoma (n = 64), pancreatic carcinoma (n = 34), gallbladder carcinoma (n = 24), metastatic carcinoma (n = 21), common bile duct carcinoma (n = 8), and hepatocellular carcinoma (n = 3). A complete follow-up was available for all patients.

RESULTS

The 30-day mortality was 9%, with no procedure-related deaths. The clinical success rate within the first 30 days was 88%. The total rate of early, procedure-related complications was 28%, and half of them were due to the percutaneous transhepatic catheter drainage procedure. Recurrent jaundice occurred in 28 (18%) patients and in 23 (82%) of these, reinterventions were made in order to relieve reobstructions. The mean length of survival for the entire patient group was 4 months, while the mean period of patency for all stents was 6 months. We found no statistically significant difference in patient survival or stent patency periods in regard to the level and cause of obstruction.

CONCLUSION

Percutaneous metallic stent placement maintains equal palliation in patients with proximal and distal malignant biliary obstructions caused by any tumor type. Most of the early complications were due to procedures performed before stent insertion and could be decreased by direct stent insertions. The most common late complication, reobstruction, is inevitable but can be easily treated in the majority of patients.

Portal venous variations. Prevalence with contrast-enhanced helical CT

PURPOSE

To review the distribution of intrahepatic portal venous branching in order to determine the prevalence of variations.

MATERIAL AND METHODS

We made a retrospective review of 655 contrast-enhanced helical CT (CECT) images of patients referred to our department for upper abdominal CT examination during an 8-month period. Of the 655 patients, 70 were eliminated from the study because of improper opacification of the portal venous system. Variations of portal venous branching in the remaining 585 patients were classified.

RESULTS

Of 585 patients, 504 (86.2%) had classical bifurcation of the main portal vein (MPV); 72 (12.3%) had a trifurcation of the MPV, 5 (0.9%) had a right anterior segmental branch originating from the left portal vein (LPV), 2 (0.3%) had an LPV originating from the right anterior segmental branch and 2 (0.3%) had a right posterior segmental branch arising from the MPV.

CONCLUSION

Variations of portal venous branching are common and helical CT is efficacious in identifying these variations.

Portal venous variations. Prevalence with contrast-enhanced helical CT

PURPOSE

To review the distribution of intrahepatic portal venous branching in order to determine the prevalence of variations.

MATERIAL AND METHODS

We made a retrospective review of 655 contrast-enhanced helical CT (CECT) images of patients referred to our department for upper abdominal CT examination during an 8-month period. Of the 655 patients, 70 were eliminated from the study because of improper opacification of the portal venous system. Variations of portal venous branching in the remaining 585 patients were classified.

RESULTS

Of 585 patients, 504 (86.2%) had classical bifurcation of the main portal vein (MPV); 72 (12.3%) had a trifurcation of the MPV, 5 (0.9%) had a right anterior segmental branch originating from the left portal vein (LPV), 2 (0.3%) had an LPV originating from the right anterior segmental branch and 2 (0.3%) had a right posterior segmental branch arising from the MPV.

CONCLUSION

Variations of portal venous branching are common and helical CT is efficacious in identifying these variations.

Biliary tuberculosis mimicking cholangiocarcinoma: treatment with metallic biliary endoprothesis

A 58-yr-old patient who presented with obstructive jaundice was evaluated with ultrasonography (US), computed tomography (CT), and percutaneous transhepatic cholangiography (PTC). Diffuse irregular stenosis of the extrahepatic bile ducts and periductal ill-defined soft tissue density along the hepatoduodenal ligament was determined. The patient was originally misdiagnosed with cholangiocarcinoma and, because the extent of disease process made surgical bypass impossible, was treated with a percutaneously inserted metallic stent. Histopathological examination of the endoluminal biopsy revealed ductal tuberculosis (TB). Most of the previous reports in the literature indicated that biliary obstruction was due to enlarged tuberculous lymph nodes compressing the bile duct. To our knowledge, only three cases of biliary stricture due to tuberculous involvement of the bile ducts were reported previously. This case illustrates the importance of tissue diagnosis in all cases of obstructive jaundice to avoid missing rare but curable diseases.

Biliary-enteric fistulas: report of five cases and review of the literature

Internal biliary fistulas (IBF) are seen rarely. Because the symptoms and signs of IBF are not specific and the diagnosis is not suspected, these patients are commonly investigated with plain abdominal films (PAF), ultrasonography (US), upper gastrointestinal series (UGIS), barium enema (BE), and computed tomography (CT), but not always with endoscopic retrograde cholangiopancreatography (ERCP). The purposes of this article are (a) to attract attention of radiologists to presumptive findings of IBF, so as not to misdiagnose this unsuspected and rare disease, and (b) review of the literature while presenting radiologic features of our cases. Five cases of IBFs in which extrahepatic biliary tree communicating with duodenum (four cases) and colon (one case) are reported. Diagnostic work-up of cases were done by PAF, US, UGIS, BE, and CT. Aerobilia, which cannot be explained using other means, ectopic gallstone and small bowel dilatation, nonvisualization of the gallbladder despite no history of cholecystectomy, and thick-walled shrunken gallbladder adherent to neighboring organs were suggestive findings of IBF in our study. Knowledge of imaging findings suggestive of IBF and a high index of suspicion increase the diagnostic rate of IBFs.