Prediction of overall survival in patients with hepatocellular carcinoma treated with Y-90 radioembolization by imaging response criteria

PURPOSE

To evaluate the potential of imaging criteria in predicting overall survival of patients with hepatocellular carcinoma (HCC) after a first transcatheter arterial yttrium-90 radioembolization (TARE) MATERIALS AND METHODS: From October 2013 to July 2017, 37 patients with HCC were retrospectively included. There were 34 men and 3 women with a mean age of 60.5±10.2 (SD) years (range: 32.7-78.9 years). Twenty-five patients (68%) were Barcelona Clinic Liver Cancer (BCLC) C and 12 (32%) were BCLC B. Twenty-four primary index tumors (65%) were>5cm. Three radiologists evaluated tumor response on pre- and 4-7 months post-TARE magnetic resonance imaging or computed tomography examinations, using Response Evaluation Criteria in Solid Tumors (RECIST) 1.1, modified RECIST (mRECIST), European Association for Study of the Liver (EASL), volumetric RECIST (vRECIST), quantitative EASL (qEASL) and the Liver Imaging Reporting and Data System treatment response algorithm. Kaplan-Meier survival curves were used to compare responders and non-responders for each criterion. Univariate and multivariate Cox proportional hazard ratio (HR) analysis were used to identify covariates associated with overall survival. Fleiss kappa test was used to assess interobserver agreement.

RESULTS

At multivariate analysis, RECIST 1.1 (HR: 0.26; 95% confidence interval [95% CI]: 0.09-0.75; P=0.01), mRECIST (HR: 0.22; 95% CI: 0.08-0.59; P=0.003), EASL (HR: 0.22; 95% CI: 0.07-0.63; P=0.005), and qEASL (HR: 0.30; 95% CI: 0.12-0.80; P=0.02) showed a significant difference in overall survival between responders and nonresponders. RECIST 1.1 had the highest interobserver reproducibility.

CONCLUSION

RECIST and mRECIST seem to be the best compromise between reproducibility and ability to predict overall survival in patients with HCC treated with TARE.

Transarterial chemoembolization (TACE) in the management of hepatocellular carcinoma: Results of a French national survey on current practices

PURPOSE

To report current practices of transarterial chemoembolization (TACE) by interventional radiologists (IR) for hepatocellular carcinoma (HCC) through a French national survey.

MATERIALS AND METHODS

An electronic survey was sent by e-mail to 232 IRs performing TACE in 32 private or public centers. The survey included 66 items including indications for TACE, technical aspects of TACE, other locally available treatments for HCC, follow-up imaging and general aspects of interventional radiology practices.

RESULTS

A total of 64 IRs (64/232; 27%) answered the survey. Each IR performed a mean of 49±45 (SD) TACE procedures per year. Marked variations in indications for TACE in HCC were observed. Six percent of IRs (4/64) treated only patients with Barcelona Clinic Liver Cancer (BCLC) stage B HCC. Antibioprophylaxis was not used by 43/64 of IRs (67%). The number of HCC nodules was considered to select conventional TACE versus drug-eluting beadsTACE (DEB-TACE) by 17/49 IRs (35%) followed by patient performance status and Child-Pugh score by 6/49 IRs (12%). Seventy-three percent of IRs (45/62) treated nodules selectively in patients with unilobar disease with cTACE. Thirty-three percent of IRs (21/64) planned systematically a second TACE session. Doxorubicin was the most frequently used drug (52/64; 81%) and 15/64 IRs (23%) used gelatine sponge as the only embolic agent. For DEB-TACE, 100-300μm beads were used by 26/49 IRs (53%) and no additional embolization was performed by 19/48 IRs (39%). Monopolar radiofrequency technique was widely available (59/63; 94%) compared to selective internal radiation therapy (37/64; 58%). Magnetic resonance imaging was used for follow-up by 13/63 IRs (20%).

CONCLUSION

Current practices of TACE for HCC varied widely among IRs suggesting a need for more standardized practices.

Usefulness of T2 ratio in the diagnosis and prognosis of cardiac amyloidosis using cardiac MR imaging

PURPOSE

To detect if a difference of T2 ratio, defined as the signal intensity (SI) of the myocardium divided by the SI of the skeletal muscle on T2-weigthed cardiac magnetic resonance (CMR) imaging, exists between patients with systemic amyloidosis, by comparison to control subjects. To determine if a relationship exists between T2 ratio and the overall mortality.

MATERIALS AND METHODS

CMR imaging examinations of 73 consecutive patients (48 men, 25 women; mean age, 63 years±15[SD]) with amyloidosis and suspicion of CA and 27 control subjects were retrospectively analyzed after institutional review board approval. Final diagnosis of CA was retained in case of histological confirmation of CA, typical pattern of CA on imaging and/or positivity of ⁹⁹Technetium-hydroxymethylene diphosphonate scintigraphy. Patients were divided in 2 groups according to the presence or the absence of CA. T2 ratios were calculated in patients with and those without CA and in control subjects with using analysis of variance. Prognostic value of T2 ratio was studied with a Kaplan-Meier curve.

RESULTS

Thirty-five patients (51%) had CA and 33 (49%) were free from CA. T2 ratio was lower in patients with CA (1.18±0.29) than in patients without cardiac involvement (1.37±0.35) (P=0.03) and control subjects (1.45±0.24) (P=0.004). A T2 ratio of 1.36 was the best threshold value for predicting CA with a sensitivity of 63% and a specificity of 73%. Kaplan-Meier analysis showed a significant relationship between a shortened overall survival and a T2 ratio<1.36.

CONCLUSION

Patients with CA exhibit lower T2 ratio on CMR imaging by comparison with patients free of CA and control subjects.

Lymphoma: imaging in the evaluation of residual masses

In the management of patients with lymphoma, imaging is essential not only for diagnosis but also to define prognosis and treatment by staging. Imaging is also used to assess the response to treatment that may affect the treatment strategy: new chemotherapeutic drug combinations and autologous stem cell transplantation. These different therapies have increased the need for higher accuracy to assess the response to treatment. Standardised imaging response criteria must be well known by radiologists involved in the management of patients with lymphoma. Criteria are mainly volumetric, and are obtained from CT scans. Functional imaging techniques have been shown to provide better information on the viability of residual masses than does CT assessment of size changes.

CT remains the main imaging technique to assess response to treatment based on volumetric international criteria. New functional imaging tools evaluating perfusion (CT and MRI), and particularly glucose uptake (PET), will probably play an important role in bringing additional information on the metabolism of lymphomatous masses.

Imaging strategies before beginning treatment of colorectal liver metastases

The management of colorectal intrahepatic metastases before resection is multidisciplinary and radiologists and nuclear medicine specialists play a major role. In accordance with the French National Guide for appropriate use of diagnostic imaging, the approach should be multimodal: a chest-abdomen and pelvic (CAP) CT scan and hepatic MRI are mandatory while PET-CT provides important additional information, in particular on intra-abdominal extrahepatic metastases. This multimodal approach emphasizes the importance of early and appropriate use of imaging in these patients, as well as the central role of multidisciplinary meetings in oncology.

[Evaluation of noninvasive diagnostic criteria for hepatocellular carcinoma on pretransplant MRI (2010): correlation between MR imaging features and histological features on liver specimen]

PURPOSE

To validate the 2010 diagnostic criteria from the American Association for the Study of Liver Diseases (AASLD) for hepatocellular carcinoma (HCC) on MRI using the surgical liver specimen as a gold standard.

PATIENTS AND METHODS

A total of 21 liver transplant recipients were retrospectively included. Each underwent surgery because of HCC between January 2007 and January 2008. Pre-transplant MRI was performed on a 1.5 Tesla MR unit. The T1W and T2W signal and kinetic contrast enhancement were correlated for each lesion with the surgical specimen. Lesion diameters between MRI and specimen were compared (Spearman). A multivariate model was created (R statistics software package) to predict the presence and grade of tumor differentiation (WHO, Edmonson Steiner).

RESULTS

A total of 71 nodules were detected at histology, including 54 HCC (mean size: 25.3mm) compared to 68 on MRI. There was moderate agreement (r=0.58, P<0.001) between the maximum lesion diameters measured on MRI and at histology. Wash-out on MRI provided an accuracy of 75 % for the detection of HCC (sensitivity=75 %, specificity=76 %). Adding T2W hyperintensity to the AASLD criteria increased the sensitivity of MRI from 70.3 % to 77.7 % for the diagnosis of HCC and from 67.6 % to 79 % for nodules less than 20mm in diameter, without affecting specificity. On multivariate analysis, wash out as a single variable was significantly associated with a diagnosis of HCC (P<0.01, odds ratio 12.0, CI 95 % [2.6-55.5]). T1W hyperintensity (P=0.04, odds ratio 5.4) and loss of signal on opposed-phase images (P=0.02, odds ratio 9.2) were predictive of good differentiation.

CONCLUSION

On MRI, the AASLD criteria or presence of wash out within a liver nodule in patients with underlying chronic hepatocellular disease are suggestive of tumoral transformation. The addition of T2W hyperintensity to the AASLD criteria increases the detection of HCC, especially nodules smaller than 20mm.

[Management of anastomotic stenosis after lower extremity bypass surgery with cutting balloon angioplasty]

PURPOSE

Conventional balloon angioplasty of anastomotic stenosis following bypass surgery is insufficient at mid- and long-term. However, short-term results with cutting balloon angioplasty (CBA) are satisfactory. The purpose of this study is to determine the long-term results using this technique. Materials and methods. Between January 2002 and January 2006, all patients with anastomotic stenosis more than one month after bypass surgery, shorter than 2 cm and>50%, were referred without randomisation to CBA.

RESULTS

A total of 19 patients with mean age of 63.5 years (55-82 years), 14 males and 5 females, were included. Twenty stenoses (femoral n=15, popliteal n=4 and calf n=1) managed with CBA affected 17 infrainguinal and 2 suprainguinal bypasses. One patient had anastomotic stenoses at both extremities. The rate of technical success aws 100%. Mean follow-up was 32 months (12-42). Three deaths occurred during follow-up. One patient presented with restenosis at 3 months, successfully treated with repeat CBA. No thrombosis or infection was observed.

CONCLUSION

The results with CBA appear persistent and compete favorably with results from surgical repair. A randomized trial would be necessary to confirm these results.

Abdominal aortic aneurysm sac behavior following Cook Zenith graft implantation: a five-year follow-up assessment of 212 cases

AIM

Aneurysm shrinkage is an expected outcome after stent-grafting for abdominal aortic aneurysm (AAA). A worrying problem following repair is progressive enlargement indicating persistent sac pressurization: in this setting not all grafts are equal. The Cook Zenith device (CZ) became available on the European market in 1999. While multicenter studies on the device have shown favorable clinical results at mid-term follow-up, few have focused on sac behavior. This study evaluated AAA sac behavior and predictive factors of its evolution by assessing the five-year results obtained with the CZ graft in a single-institution experience.

METHODS

All consecutive elective surgery patients treated with a CZ graft for infrarenal aortic or aortoiliac aneurysm repair from January 2000 to November 2004 in our institution were included prospectively in the study and followed at 1, 6, 12, 18, 24 months and yearly thereafter. Pre-, intra- and postoperative data were recorded in a computerized database. Computed tomography (CT) scans were reviewed by a senior radiologist to identify any abnormalities including endoleak and graft malfunction. Pre- and postoperative maximum sac diameters were derived from measurements of CT findings and then compared. A change of at least 8 mm in sac size was considered significant. Overall results are expressed according to the Committee on Reporting Standards of AAA treatment. Factors that may have influenced sac behavior were analyzed by dividing the patients into 3 groups according to whether the sac diameter remained unchanged (group 1), had increased (group 2) or regressed (group 3). Statistical analysis of the demographic and CT-scan data was then performed.

RESULTS

The study sample was 212 consecutive patients (mean age 72.8+/-9.0 years); the mean aneurysm diameter before treatment was 55.5+/-9.8 mm. All stent grafts were successfully implanted. The 30-day mortality rate was 0.94% (2/212); the morbidity rate was 11.7% (25/212). The primary technical success rate was 93.40%; the assisted primary technical success and secondary technical success rates were 96.63% and 99.52%, respectively. The mean follow-up period was 17.7+/-14.7 (1-60) months. The cumulative survival probability was 94%, 84.2%, and 72.9% at 12, 24, and 36 months, respectively. The endoleak-free survival probabilities at 12 and 24 months were 75.7% and 62.8%, respectively. The free of intervention survival rates were 82.1%, 68.9% and 60.6% at 12, 24 and 38 months, respectively. At five years follow-up, the overall clinical success rate was 49.5%. If changes in sac diameter occurred, they were noted at 13 months on average. Sac size remained unchanged in 115 (54.3%) patients (group 1), increased in 9 (4.2%) (group 2), and regressed in 88 (41.5%) (group 3). Neither preoperative patient demographics nor aneurysm characteristics were found to be predictive of sac behavior. Aortouniliac graft configuration was predictive of sac shrinkage (P=0.020). Endoleak was more frequent among patients in groups 1 (27/115; 23%) and 2 (5/9; 56%) than among those in group 3 (9/88;10%) (P=0.001). Reduction in aneurysm sac diameter was less marked in patients with any type of endoleak (P=0.0003).

CONCLUSION

The CZ grafts offered satisfactory overall results up to five years of follow-up; nevertheless, sac diameter increased in 4.25% of patients. Endoleak was a predictive factor of a lack of sac shrinkage, while aortouniliac graft configuration was predictive of sac shrinkage.

Limb Graft Occlusion Following EVAR: Clinical Pattern, Outcomes and Predictive Factors of Occurrence

INTRODUCTION

We reviewed our experience with limb occlusion after EVAR in order (1) to assess the clinical pattern and treatment options (2) to assess outcomes and (3) to identify predictive factors of occurrence.

MATERIALS AND METHOD

Between 1995 and 2005, 460 AAA patients were electively treated with a variety of commercially available stent grafts. There were 369 bifurcated and 91 aortouniiliac grafts (829 limbs). Follow-up included physical examination, plain X-ray, Duplex ultrasonography, and spiral computed tomographic scans at 1, 6, 12 months and annually thereafter. All pertinent data were collected prospectively and analysed retrospectively. The follow-up period ranged from Day 0 to 104 months, with a median follow-up of 23.4 months.

RESULTS

36 limbs in 33 patients (7.2%) occluded between Day 0 and 71 months (average: 9.5 months) after EVAR. Presentation was acute ischemia in 11 cases, rest pain in 9, claudication in ten. Four occlusions remained asymptomatic and two occurred intraoperatively. Treatment was femoro-femoral cross-over graft in 19 cases, axillo-femoral bypass in three, thrombectomy and stent in three, thrombolysis and stent in nine, and conservative in two. One patient (3%) died of multiple organ failure after thrombolysis. There was no amputation. Reocclusions occurred in two patients (6.1%). Multivariate logistic regression showed that kinking (odds ratio [OR] 11.9; confidence interval [CI] 3.39-42.1; p=0.0001), first graft generation (OR 2.87; CI 1.25-6.62; p=0.017) and younger age (OR 1.05; CI 1.00-1.09; p=0.034) were independently related to the occurrence of graft limb occlusion.

CONCLUSION

Acute graft limb occlusion is not rare after EVAR. The frequency of limb occlusion has declined with current stent grafts generation. Although surgery and endovascular treatments are efficient and safe, development of a graft limb kink should lead to aggressive pre-emptive treatment to prevent occlusion.

The Safety and Efficacy of Angioseal in Therapeutic Endovascular Interventions

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of the closure device Angioseal.

MATERIAL AND METHODS

All consecutive patients, who underwent a therapeutic radiological intervention using the femoral artery approach from January 2001 to January 2005 in the Service of Vascular Surgery, Henri Mondor Hospital, Creteil, France, were prospectively included in the study. The efficacy of Angioseal was defined by the ability of the device to cover the puncture site and stop bleeding. The safety was defined by the rate of complications.

RESULTS

A total of 79 Angioseal devices were employed on 77 patients. There were 62 (78.5%) males and 17 (21.5%) females. The mean age of the patients was 65.2+/-11.6 years (mean+/-SD). All Angioseal devices were deployed successfully. There were 62 (78.4%) 6F and 17 (21.6%) 8F sheaths employed during the procedures. There were two minor (2.5%) hematomas, one (1.2%) major hematoma and one (1.2%) pseudoaneurysm after the procedure. The mean time of discharge from the hospital was 2.1+/-1.8 (mean+/-SD) days. The patients were followed up for a mean of 9.0+/-9.3 (1-60 months) months.

CONCLUSIONS

Angioseal provides a safe and effective way of closing the femoral artery puncture site with acceptable morbidity rates.

Risk factors and long-term outcome of transplant renal artery stenosis in adult recipients after treatment by percutaneous transluminal angioplasty

Transplant renal artery stenosis (TRAS) is a common complication of kidney transplantation but attempts to identify predisposing risk factors for TRAS have yielded conflicting results. In order to determine the predisposing factors for transplant (TRAS), we retrospectively reviewed the records of 29 renal allograft recipients with TRAS treated with percutaneous transluminal angioplasty (PTA). The TRAS group was compared with a case-control group of 58 patients. Predisposing factors for TRAS included CMV infection (41.4% vs. 12.1% p = 0.0018) and initial delayed graft function (DGF) (48.3% vs. 15.5% p = 0.0018), respectively in the TRAS and the control group. Acute rejection occurred more frequently in patients from the TRAS group (48.3%) compared with the control group (27.6%), although the difference was not significant (p = 0.06). In a multivariate analysis, only CMV infection (p = 0.005) and DGF (p = 0.009) appear to be significantly and independently associated with TRAS. The long-term graft survival was significantly higher in the control group, compared with the TRAS group (p = 0.03). Our study suggests that CMV infection and DGF are two reliable risk factors for TRAS. Despite treatment by PTA with primary successful results, TRAS significantly affects long-term graft outcome.

Emergency Endovascular Repair for Ruptured Abdominal Aortic Aneurysms: Feasibility and Comparison of Early Results with Conventional Open Repair

PURPOSE

To assess the feasibility of endovascular aortic repair (EVAR) on patients presenting with a ruptured abdominal aortic aneurysm (AAA) in a teaching hospital, and to compare there post-operative outcomes with contemporaneous patients treated with open repair (OR).

METHODS

A series of consecutive of patients presenting ruptured AAA with retro/intraperitoneal haematoma were included in the study. EVAR was attempted whenever possible. In all other cases (severe haemodynamic instability, adverse anatomy, device unavailability), ruptured AAA were treated by OR.

RESULTS

Thirty-seven patients were enrolled between January 2001 and July 2004. Seventeen (46%) patients were treated using adapted designed aortoiliac endografts (eight bifurcated, eight aorto-uniiliac, one iliac extension). Twenty (54%) patients unfit for EVAR because of severe haemodynamic instability (n=8), adverse anatomical configuration (n=7), or unavailability of an appropriate endograft (n=5) were treated by OR. Twenty-seven (73%) had a retrospective suitable anatomy for EVAR. Three early conversions from EVAR to OR were performed. Blood loss, operating time, and intensive care stay were significantly decreased in EVAR patients (respectively: 156 min+/-60, 1520 ml+/-1175, 3 days for EVAR; vs. 222 min+/-82, 3075 ml+/-1750, 13 days for OS; P<.01). The 30-day mortality rate was 23.5% for EVAR vs. 50% for OR (P=0.09).

CONCLUSION

EVAR of ruptured AAA is feasible for selected patients based on haemodynamic and morphologic criteria, and should be associated with improved immediate outcomes as compared with OR. These results should be tempered by the fact that these patients have heavy comorbidities which explains the absence of difference in mid-term mortality rates between the two groups, but should also encourage surgical institutions that are managing such life-threatening emergencies to introduce EVAR as part of their therapeutic arsenal for ruptured AAA.

Endovascular repair for ruptured AAA: a literature review

The reduced physiological impact of endovascular aneurysm repair (EVAR) compared with conventional open repair has been demonstrated. If this technique could be used routinely in patients with ruptured abdominal aortic aneurysm (AAA) it may reduce the high peri-operative mortality. This review of the literature identified the current experience with EVAR of ruptured AAA. Only a small number of case series with selected patients are reported. These patients were selected for their haemodynamic stability, and their suitable aneurysm morphology. The overall anatomic suitability rates for EVAR reported, suggest an applicability of 58% to 80% from an intent-to-treat experience. The average post-operative mortality rate was 24%, ranging from 9 to 45% and may reflect increasing experience and patient selection. Important lessons have been learned from these first experiences that help to define a clear position of EVAR as an additional therapeutic option for ruptured AAA.

Subintimal Angioplasty: Feasible and Durable

OBJECTIVE

To assess prospectively the feasibility and durability of subintimal angioplasty (SA) clinically and by duplex scans every 3 months.

PATIENTS AND METHODS

Within a period of 54 months, we selected 96 patients with 100 occlusions (mean length: 11.5 cm) of femoro-popliteal or tibial arteries, for SA.

RESULTS

The technical success rate was 88% and seven out of 12 failures were treated by conventional surgery. Five below-the-knee amputations were performed despite a patent recanalization. The following complications occurred: arterial perforation (6), arterial thrombosis (4), extensions beyond the planned re-entry site (5), and arterial dissection (2). Primary, assisted-primary and secondary patency rates were 61, 68 and 74%, respectively at 24 months. The 24 month-limb salvage and survival rates were 78 and 85%, respectively. Duplex imaging demonstrated 10 restenosis (five symptomatic >70%, five asymptomatic 30-70%), seven occlusions (five asymptomatic, two symptomatic treated by a bypass) and one asymptomatic dilatation.

CONCLUSION

In a selected group of patients SA is feasible with a high initial technical success rate. SA is a good alternative in patients who are poor candidates for bypass surgery.

Multimodal therapy with intravenous biweekly leucovorin, 5-fluorouracil and irinotecan combined with hepatic arterial infusion pirarubicin in non-resectable hepatic metastases from colorectal cancer (a European Association for Research in Oncology trial)

BACKGROUND

The purpose of this study was to evaluate the tolerance and efficacy of combining i.v. irinotecan, 5-fluorouracil (5-FU) and leucovorin (LV) with hepatic arterial infusion (HAI) of pirarubicin in non-resectable liver metastases from colorectal cancer.

PATIENTS AND METHODS

Thirty-one patients were included in a phase II trial with i.v. irinotecan/5-FU/LV administered every 2 weeks, combined with HAI pirarubicin 60 mg/m(2) on day 1 every 4 weeks. In most cases HAI was administered via a percutaneous catheter.

RESULTS

The main grade 3/4 toxicity was neutropenia, encountered in 78% of the patients. When all patients were considered in the analysis, tumour response rate was 15 out of 31 [48%; 95% confidence interval (CI) 32% to 65%]. Liver resection was made possible in 11 patients (35%; 95% CI 21% to 53%). There were no toxic death. Median overall survival was 20.5 months, and median progression-free survival was 9.1 months. In patients with completely resected metastases, median overall survival was not reached and median progression-free survival was 20.2 months.

CONCLUSION

The multimodality approach used in the present study was well-tolerated and yielded dramatic responses. An aggressive approach combining i.v. and HAI chemotherapy deserves further investigation.

[Rupture of a jejunal artery pseudo-aneurysm after a cephalic duodenopancreatectomy]

Arterial pseudo-aneurysms complicating pancreaticoduodenectomy are rare but have a poor prognosis. They usually result from arterial erosion due to pancreatic fistula. The authors report a pseudo-aneurysm with an uncommon localization (first jejunal artery), diagnosed after a negative first arteriography, and successfully treated by radiological embolization. Special features of pseudo-aneurysms complicating pancreaticoduodenectomy are reviewed.

MRI and PET of bone marrow in lymphoproliferative diseases

In lymphoproliferative diseases, bone marrow involvement (BMI) is an essential parameter influencing staging, prognosis and treatment. In addition to pathological analysis of blind bone marrow biopsy, MRI and PET can help to (a) estimate initial BMI and assess the stage of disease, (b) indicate prognosis and (c) assess response to treatment. Regarding diagnosis, the MR patterns of focal and diffuse BMI will be reviewed, and compared to the MR appearance of normal marrow. The technique and the results of dynamic contrast-enhanced (DCE) MRI regarding normal and tumoral marrow will be detailed. An approach of the perfusion parameters of normal and tumoral marrow will thus be presented. The changes of MR patterns linked to BMI will be described after treatment and correlated to the response to treatment of patients with lymphoma and myeloma. Although ¹⁸F-FDG-PET has been extensively studied in the management of lymphoma, few studies have examined its value for assessing BMI. ¹⁸F-FDG-PET seems to be accurate for this purpose in patients with lymphoma and myeloma. The limitations of MR imaging and ¹⁸F-FDG-PET will be detailed. In conclusion, MRI and PET imaging including the functional approach of perfusion by DCE-MR imaging and glucose uptake by ¹⁸F-FDG-PET can contribute to the management of patients with lymphoproliferative diseases by its ability to analyse BMI.

Focal nodular hyperplasia of the liver in men: is presentation the same in men and women?

BACKGROUND

Focal nodular hyperplasia (FNH) of the liver is a benign hepatic lesion relatively common in women. No studies specifically designed to describe the presentation and imaging findings in males have been published.

AIMS

The aims of this study were: (a) to describe the clinical and imaging findings in 18 men with FNH, and (b) to compare these data with those observed in 216 women with FNH observed during the same nine year period.

PATIENTS AND METHODS

According to a final diagnosis of FNH assessed either by pathological examination or by magnetic resonance (MR), the medical charts of 18 men with FNH observed at our institution were reviewed. In order to compare clinical and MR presentations, the files of 216 women with a total of 291 FNH lesions, investigated during the same nine year period, were reviewed.

RESULTS

Eighteen FNH lesions, with a mean diameter of 37.5 mm, were demonstrated in the 18 male patients. A total of 291 lesions with a mean diameter of 63.4 mm were comparatively demonstrated in 216 female patients. Mean age at diagnosis was significantly higher in men (p<0.01) and mean FNH size was significantly smaller in men (p<0.001). Surgery was more frequently performed in men (72.2%) than in women (16.7%) (p<0.001).

CONCLUSIONS

Our data indicate that FNH is rare in men and that the lesions are smaller and more often atypical than those in women.

[Endoprostheses for aneurysms of the abdominal aorta. A technical innovation, a cultural revolution]

FACTS

A revolutionary technology has totally renovated the treatment of aneurysms of the abdominal aorta. Classical "dissection-graft" procedures require a wide abdominal incision with clamping and declamping times, and often major blood loss. Perioperative mortality varies from 3% to 7% depending on the team's experience and the presence of comorbidities. Complications occur in 30% of the patients; often benign they can be quite serious. As direct consequence of the development of peripheral stents, endoprostheses can now be introduced via the femoral route through a short inguinal incision. Operative trauma is considerably reduced, greatly shortening the recovery time. Mortality is low, of around 1%, and postoperative complications are much less frequent and much less severe. There is also a 3-fold reduction in the duration of the hospital stay.

PREREQUISITES

All aneurysms cannot be treated with this method. The anatomy of the aneurysm and the iliac arteries is a determining factor. The iliac vessels must be large enough and devoid of important obstruction (kinks, atheromatous plaques) in order to access the aorta. The subrenal collar must measure at least 1 cm and be free of severe calcifications or thrombi. A rigorous preoperative exploration, using CT-scan with 3D reconstruction and graduated arteriography, is necessary. The length and diameter of the prosthesis is calculated from the results and must be perfectly adapted to avoid failure.

UNKNOWNS

Long-term outcome remains unknown. The endoprosthesis excluded the aneurysm from the blood stream, depressurizing the aneurysmal sac. Endoprosthetic leakage can occur in case of defective application or by reflux from lumbar or inferior mesenteric arteries or due to leakage of the endoprosthesis itself. In such cases, the aneurysm can continue to progress. This explains the need for careful follow-up with duplex Doppler and/or CT-scan in treated patients. If the treatment is incomplete, complementary procedures may be necessary, often via an endovascular route or in some cases with conversion to conventional surgery.

EVALUATIONS

Improved prosthetic design and durability is an important point. Randomized studies organized in France, as well as in England and Holland and the United States, are currently assessing the contribution of this new technique and its relative role compared with conventional surgery.

Spontaneous hemomediastinum complicating steroid-induced mediastinal lipomatosis

Spontaneous hemomediastinum is a rare event, occurring in association with bleeding disorders, intratumoral bleeding, or following an abrupt increase in intrathoracic pressure. We report the case of a patient with systemic lupus erythematosus, nephrotic syndrome, and renal failure, in whom mediastinal lipomatosis (ML) developed following increased corticosteroid therapy. Anticoagulant therapy likely precipitated a massive spontaneous hemomediastinum secondary to diffuse hemorrhage of mediastinal fat, which required emergency decompressive surgery. Steroid-induced ML is common and usually well tolerated, but clinicians should be aware of its potential risk of bleeding when associated with anticoagulant therapy. This case further emphasizes the bleeding complications of treatment with low-molecular-weight heparin in patients with renal failure.

Technical aspects and current results of carotid stenting

PURPOSE

We reviewed our experience with carotid stenting (CS), focusing on technical evolution and results.

METHODS

From September 1995 to February 2000, 77 patients with 83 internal (n = 68) and common carotid artery lesions (n = 15) were selected for CS. This patient population was categorized into three consecutive periods based on patient selection, material, and technical skills. For internal carotid artery lesions, period I included 11 patients treated by means of direct carotid puncture with balloon expandable stents; period II included 42 patients treated by means of a femoral approach with self-expandable stents; and period III included 15 patients in whom monorail system and cerebral protection devices were used. Common carotid artery lesions were treated by means of carotid puncture in five patients and by means of a femoral approach in 10 patients. In only two of the latter cases, cerebral protection devices were used.

RESULTS

The overall immediate success rate, defined as successfully treated stenosis with no neurological events, was 89.7% for internal carotid artery lesions and 100% for common carotid artery lesions. All neurological events, which consisted of reversible events (4.4%), minor stroke (1.5%), and major stroke (2.9%), occurred during periods I and II. In periods I, II, and III, the rate of surgical conversion was 18%, 9.5%, and 0%, respectively, the rate of transient ischemic attack and reversible ischemic neurologic deficit was 0%, 7%, and 0%, respectively, and the rate of minor and major stroke was 0%, 7%, and 0%, respectively. All major strokes were cleared with intra-arterial thrombolysis. At discharge, the success rates defined by means of the absence of conversion and neurological events were 82% during period I, 76% during period II, and 100% during period III. The freedom from neurological deficits rates were 100%, 97.6%, and 100%, respectively. During follow-up, six significant asymptomatic restenoses were detected with duplex scanning; however, only one patient required reintervention.

CONCLUSION

Technical skills and technological improvement, including low-profile balloon and catheter, cerebral protection device, and intra-arterial rescue techniques, may reduce the rate of neurological events associated with CS. Technical improvements should be given careful consideration before the initiation of randomized trials comparing CS and carotid endarterectomy.

[Left ventricular functional imagery by magnetic resonance. Applications and developments]

Technical developments have considerably reduced the acquisition time and have improved the quality of magnetic resonance imaging. The recent recommendations of the European Society of Cardiology place MRI in the front line of investigations for the diagnosis and evaluation of congenital heart disease, cardiac tumours and pathology of the pericardium and great vessels. With the possibility of obtaining oblique planes in all 3 dimensions, MRI is the reference for the measurement of left ventricular mass, volumes, and ejection fraction, with the major advantage of not depending on hypotheses of left ventricular geometry. In addition to these known applications, the development of functional cardiac MRI has led to significant advances in the study of regional myocardial function and perfusion. The aim of this article is to discuss present indications and the potential developments of functional cardiac MRI, focusing on the quantitative evaluation of myocardial function and perfusion.

Percutaneous stenting of an latrogenic superior mesenteric artery dissection complicating suprarenal aortic aneurysm repair

PURPOSE

To report endovascular repair of an iatrogenic superior mesenteric artery (SMA) dissection caused by a balloon occlusion catheter.

CASE REPORT

A 68-year-old man with a suprarenal aortic aneurysm underwent conventional prosthetic replacement, during which visceral artery back bleeding was controlled with balloon occlusion catheters. Six hours postoperatively, the patient experienced an episode of bloody diarrhea with abdominal pain and tenderness and mild metabolic acidosis. Colonoscopy revealed colitis (grade I) without necrosis of the right and left colon. An emergent abdominal computed tomographic scan showed signs of mesenteric ischemia with bowel dilatation and SMA wall hematoma; angiography identified a dissection 1 cm distal to the SMA origin. An Easy Wallstent was deployed percutaneously, successfully reestablishing SMA patency. The postoperative course was uneventful, and the patient remains asymptomatic with a patent SMA stent and aortic graft at 1 year.

CONCLUSIONS

latrogenic SMA dissection should be suspected after suprarenal aortic aneurysm repair if signs of mesenteric ischemia arise. Prompt and thorough imaging studies are necessary to confirm the diagnosis and assess the potential for an endoluminal treatment.

Mid-term results of endovascular versus open repair for abdominal aortic aneurysm in patients anatomically suitable for endovascular repair

OBJECTIVES

to prospectively evaluate the mid-term results of endovascular and open repair in patients with abdominal aortic aneurysm (AAA) anatomically suitable for endovascular repair.

MATERIAL AND METHODS

between January 1995 and March 1999, among 438 patients treated for AAA, 180 (41%) were suitable for endovascular repair as assessed by computed tomography (CT) scan and angiogram. Seventy-three were treated by various commercially available endovascular grafts (EV) and 107 by open repair (OR). Postoperatively, patients were followed every 6 months with clinical examination, duplex scan and in the EV group, CT scans. Patients>> demographic data, intra- and postoperative events were recorded prospectively in a computerised database and compared for each group.

RESULTS

median age, sex ratio, preoperative risk factors and aneurysm diameters were not statistically different between the two groups. Respectively in the EV and OR, the average duration of operation was 149+/-73 mn, and 133+/-44 mn (NS), blood loss 96 ml+/-28 and 985 ml+/-113 (p<0.01), duration of hospitalisation 7 days+/-2 and 13 days+/-7 (p<0.01). The one-month mortality was 2.7% (n=2) for EV and 2.8% (n=3) for OR. The rate of cardiac and pulmonary complications was significantly higher in the OR group (6. 9% versus 19.6%, p=0.017). At a mean follow-up of 1 year, the cumulative survival rate was 82.2%+/-7.5 for EV and 96%+/-2.12 for OR (log-rank test p=0.043). No patients died of rupture, but three patients had to be converted to open surgery. Twenty-two percent (n=16) patients in the EV and 7.5% (n=8) in the OR were submitted to a subsequent minor or major reintervention (p=0.007). At 1 year, the cumulative rates free of any reintervention were respectively 78. 8%+/-6.7% and 92.9%+/-2.7% (p=0.001). In the EV there were 17 early endoleaks (23.3%). At the end of patient's follow-up seven endoleaks (9.6%) persisted. The primary success rate defined by the absence of endoleak and the absence of reintervention was 54 (74%) with EV and 101 (94%) with OR (p=0.001).

CONCLUSION

EV is a promising technique. However, with current devices and indications the immediate benefits, mainly less blood loss, fewer cardiac and pulmonary complications, and shorter hospitalisation time, are outweighed by a higher rate of reinterventions to treat endoleak, or to maintain patency of the graft.

Placement of a fenestrated Palmaz stent across the renal arteries. Feasibility and outcome in an animal study

OBJECTIVES

To investigate the feasibility of placing stents across renal arteries. Design we have studied in pigs: (i) the feasibility of accurately placing a fenestrated stent in front of one renal ostium; (ii) the short-term effects on renal arteries and function after the placement of such a fenestrated stent.

MATERIALS AND METHODS

Eight fenestrated Palmaz stents were placed over pigs' renal ostia under fluoroscopy. Five weeks later, angiograms were performed and the animals were sacrificed. Proliferation of the healing tissues over the ostia was measured and analysed by microscopy. Serum creatinine was measured prior to all angiograms and at 5 weeks.

RESULTS

All eight stents were correctly placed. One stent later migrated and was excluded from the study. One pig died at day 1. Gross examination confirmed the correct placement of the fenestrations in four pigs out of seven (57%). In the six remaining pigs, at 5 weeks, there was no angiographic evidence of stent misplacement and all the kidneys were fully perfused. Nine renal ostia were covered by struts and neointima with a mean area of coverage of 38+/-5% altogether. No tissue proliferation was observed over the three renal ostia located in front of the fenestration. Serum creatinine did not significantly increase at 5 weeks.

CONCLUSION

Creating a fenestration in a stent for renal arteries may be worth while in order to avoid neointimal covering of the renal ostia. However, accurate placement of such a fenestrated stent remains a difficult task.

Oral contraceptive use and focal nodular hyperplasia of the liver

BACKGROUND & AIMS

Because most patients with focal nodular hyperplasia (FNH) are young women, an important decision is whether to discontinue oral contraceptive (OC) use. The aims of this study were to evaluate (1) the number and size of FNH lesions in women with various patterns of OC use and in women without OC use and (2) the modifications in the number and size of FNH lesions during follow-up, according to OC use.

METHODS

In a 9-year study in 216 women with FNH, the diameter and number of lesions documented by magnetic resonance (MR) imaging were evaluated (1) at diagnosis according to OC use as follows: group A, no OC use (n = 28); group B, high-dose OC use (n = 46); group C, low-dose OC use (n = 98); group D, successive use of high-dose and low-dose OCs (n = 33); and group E, use of progestogens only (n = 11); and (2) during follow-up in 136 women, 14 of whom were OC nonusers who stayed off OCs, 89 discontinued OC use, 26 took low-dose OCs, and 7 stayed on a progestogen only. Twelve women became pregnant. In 168 women, the diagnosis of FNH was made based on a combination of rigorously defined MR criteria. In the remaining 48 patients, diagnosis was by surgical biopsy (n = 36) or resection (n = 12). Mean diameter and number of lesion(s) per patient were assessed by MR imaging using the same protocol in all study patients.

RESULTS

No significant differences in the number or size of lesions were found in the 5 patient groups. During follow-up, a change in lesion diameter occurred in only 4 women; this event was not influenced by OC use. In the 12 patients who became pregnant, lesion size was unchanged after delivery, pregnancy was uneventful, and delivery occurred spontaneously.

CONCLUSIONS

These data suggest that (1) neither the size nor the number of FNH lesions are influenced by OC use; (2) size changes during follow-up are rare and do not seem to depend on OC use; and (3) pregnancy is not associated with FNH changes or complications.

Unexpected MR-T1 enhancement of endocrine liver metastases with mangafodipir

With the use of available liver magnetic resonance contrast agents, such as mangafodipir (Mn-DPDP), liver metastases do not exhibit enhancement on T1-weighted images. This absence of enhancement is due to the lack of hepatocytes within these tumors. The purpose of this report is to demonstrate an unexpected enhancement on T1-weighted images 30 minutes after injection of mangafodipir, in the case of endocrine liver metastases from a non-hyperfunctioning neuroendocrine pancreatic tumor. Different hypotheses could explain this unexpected enhancement, such as increased arterial tumoral flow or high metabolic activity. Contrary to liver metastases of other origins, Mn-DPDP enhancement can be present in neuroendocrine metastases. J. Magn. Reson. Imaging 1999;10:193-195.

Surgical transluminal iliac angioplasty with selective stenting: long-term results assessed by means of duplex scanning

PURPOSE

The safety of iliac angioplasty and selective stenting performed in the operating room by vascular surgeons was evaluated, and the short- and long-term results were assessed by means of serial duplex scanning.

METHODS

Between 1989 and 1996, 281 iliac stenotic or occlusive lesions in 235 consecutive patients with chronic limb ischemia were treated by means of percutaneous transluminal angioplasty (PTA) alone (n = 214) or PTA with stent (n = 67, 23.8%). There were 260 primary lesions and 21 restenosis after a first PTA, which were analyzed separately. Stents were implanted in selected cases, either primarily in totally occluded arteries or after suboptimum results of PTA (ie, residual stenosis or a dissection). Data were collected prospectively and analyzed retrospectively. Results were reported in an intention-to-treat basis. Clinical results and patency were evaluated by means of symptom assessment, ankle brachial pressure index, and duplex scanning at discharge and 1, 3, 6, and every 12 months after angioplasty. To identify factors that may affect outcome, 12 clinical and radiological variables, including the four categories of lesions defined by the Standards of Practice Committee of the Society of Cardiovascular and Interventional Radiology, were analyzed separately. The statistical significances of life-table analysis of patency were determined by means of the log-rank test.

RESULTS

There were no postoperative deaths or amputations. Local, general, and vascular complications occurred in 2.1%, 1.3% and 4.7% of cases, respectively (total, 8.1%). The mean follow-up period was 29.6 months. The cumulative patency rates +/- SE of the 260 PTAs (including 55 PTAs plus stents) were 92.9% +/- 1.5% at 1 month, 86. 5% +/- 1.7% at 1 year, 81.2% +/- 2.3% at 2 years, 78.8% +/- 2.9% at 3 years, and 75.4% +/- 3.5% at 5 and 6 years. The two-year patency rate of 21 redo PTAs (including 11 PTAs plus stents) was 79.1% +/- 18.2%. Of 12 predictable variables studied in the first PTA group, only the category of the lesion was predictive of long-term patency. The two-year patency rate was 84% +/- 3% for 199 category 1 lesions and 69.7% +/- 6.5% for 61 category 2, 3, and 4 lesions together (P =. 02). There was no difference of patency in the stented and nonstented group.

CONCLUSION

Iliac PTA alone or with the use of a stent (in cases of occlusion and/or suboptimal results of PTA) offers an excellent long-term patency rate. Categorization of lesions remains useful in predicting long-term outcome. PTA can be performed safely by vascular surgeons in the operating room and should be considered to be the primary treatment for localized iliac occlusive disease.

[Transluminal treatment of abdominal aortic aneurysms. Might one obstruct the renal arteries?]

During transluminal treatment of an aneurysm of the abdominal aorta, the proximal part of the stent may sometimes lay over the ostia of the renal arteries. Animal studies have shown various scarring patterns depending on the type of stent used and its duration of implantation. The Gianturco and Wallstent appear to be better tolerated than the Palmaz stents. The AA have shown that, with the Strecker stents, a neointima developed between the meshes of the stent over a surface of 43% +/- 30% in 6 weeks. May and Parodi report some occlusions in their clinical series. In the AA's series using Vanguard, no renal artery was thrombosed despite the fact that the stent lay over the artery on 2 occasions in 105 patients. In conclusion, the consequences of the proximal part of a stent laying over the ostium of a renal artery depend mainly on the type of stent used. "Wide mesh" stents are probably the best to use to prevent serious renal complications.

[Which investigations should be selected for the preoperative assessment before the decision for treatment of abdominal aortic aneurysm by endoprosthesis: arteriography, tomodensitometry or magnetic resonance imaging?]

PURPOSE

To determine the best imaging technique to obtain all the necessary information before the placement of an aortic endoprosthesis.

METHOD

Each technique is assessed from a review of the literature and the AA's own experience (21 endoprostheses); the advantages and disadvantages of each technique are discussed.

RESULTS

1) Arteriography (with a calibrated catheter), always considered at the investigation of choice to determine the feasibility of the technique, gives no information on the aortic wall; 2) spiral CT scanning is superior to basic scanning in giving a 3-dimensional picture. Many authors have concluded that spiral CT-scanning has replaced aortography, but its limitation, at the moment, is in the quality of the assessment of the renal arteries (number, stenosis); 3) magnetic resonance imaging has not been studied to any extent in terms of assessment for endoprosthetic treatment. Early results are promising and will be described.

CONCLUSIONS

At the present time, the best compromise is spiral-CT scanning in thin sections with 3-dimensional reconstruction. The AA combine this with arteriography to visualise the renal arteries in particular, and the distal bed.

[Role of magnetic resonance imaging in liver pathology]

The increasingly common use of ultrasound examination of the liver has led to increased detection of hepatic tumours, showing a hitherto unsuspected prevalence. Improved techniques in MRI, such as dynamic sequences and new contrast media, are ameliorating the detection and characterization of the lesions, in particular with regard to computed tomography. In addition, since MRI is more sensitive to different components than in computed tomography, it permits better study of diffuse diseases such as haemochromatosis or fatty infiltration, particularly in pseudotumoural forms. The continuing progress in system improvement makes MRI an excellent method for diagnosis of bile duct disorders, especially in case of obstruction.

[In adult urology, when should ultrasonography, computed tomography, intravenous urography be requested?]

The authors recall the indications for the medical imaging examinations most frequently used in adult urology, depending on the organ, syndrome or disease to be investigated. The indications for intravenous urography (IVU) are increasingly rare, but it remains the reference examination to study the pyelocaliceal cavities. Ultrasonography, combined with KUB, generally provides a diagnosis, especially in the emergency setting. Computed tomography (CT) is the reference examination for the investigation of all types of renal lesions, but also lesions of other organs, especially in the case of neoplastic disease.