Idarubicin-loaded beads for chemoembolisation of hepatocellular carcinoma: results of the IDASPHERE phase I trial

BACKGROUND

A phase I dose-escalation trial of transarterial chemoembolisation (TACE) with idarubicin-loaded beads was performed in cirrhotic patients with hepatocellular carcinoma (HCC).

AIM

To estimate the maximum-tolerated dose (MTD) and to assess safety, efficacy, pharmacokinetics and quality of life.

METHODS

Patients received a single TACE session with injection of 2 mL drug-eluting beads (DEBs; DC Bead 300-500 μm) loaded with idarubicin. The idarubicin dose was escalated according to a modified continuous reassessment method. MTD was defined as the dose level closest to that causing dose-limiting toxicity (DLT) in 20% of patients.

RESULTS

Twenty-one patients were enrolled, including nine patients at 5 mg, six patients at 10 mg, and six patients at 15 mg. One patient at each dose level experienced DLT (acute myocardial infarction, hyperbilirubinaemia and elevated aspartate aminotransferase (AST) at 5-, 10- and 15-mg, respectively). The calculated MTD of idarubicin was 10 mg. The most frequent grade ≥3 adverse events were pain, elevated AST, elevated γ-glutamyltranspeptidase and thrombocytopenia. At 2 months, the objective response rate was 52% (complete response, 28%, and partial response, 24%) by modified Response Evaluation Criteria in Solid Tumours. The median time to progression was 12.1 months (95% CI 7.4 months--not reached); the median overall survival was 24.5 months (95% CI 14.7 months--not reached). Pharmacokinetic analysis demonstrated the ability of DEBs to release idarubicin slowly.

CONCLUSIONS

Using drug-eluting beads, the maximum-tolerated dose of idarubicin was 10 mg per TACE session. Encouraging responses and median time to progression were observed. Further clinical investigations are warranted (NCT01040559).

Body fat distribution and adipokine secretion are not associated with diabetic retinopathy in patients with type 2 diabetes mellitus

AIMS

The link between diabetic retinopathy (DR) and adipokines is controversial. Some studies suggest that visceral fat and adipokines could be additional risk factors for DR. The aim of this study was to determine the relationship between abdominal fat or adipokine secretion and DR in patients with type 2 diabetes mellitus (DM).

METHODS

A total of 179 patients with type 2 DM were included. Each patient underwent measurement of plasma adiponectin and leptin and an evaluation of body fat distribution (visceral and subcutaneous) with MRI. The severity of DR was evaluated according to the classification of the American Academy of Ophthalmology. Patients were classified in 3 groups: absence of DR, mild and moderate DR, and advanced DR (severe, proliferative and laser-treated DR).

RESULTS

There were no significant differences between the 3 groups for adiponectin, leptin and visceral or subcutaneous fat accumulation. Patients with DR had a mean duration of diabetes, serum creatinine concentration and percentage of macroalbuminuria significantly higher than patients without DR (p < 0.001, p = 0.003 and p < 0.001, respectively). Serum adiponectin increased with the diabetic nephropathy stage (p = 0.007).

CONCLUSIONS

Our study suggests that body fat distribution and adipokine secretion are not associated with DR in patients with type 2 DM.

Increased erythrocytes n-3 and n-6 polyunsaturated fatty acids is significantly associated with a lower prevalence of steatosis in patients with type 2 diabetes

BACKGROUND & AIMS

Non-alcoholic fatty liver disease (NAFLD) is commonly associated with obesity, metabolic syndrome and type 2 diabetes. Although dietary fat contributes substantially to the accumulation of liver fat, the role of individual fatty acids in this accumulation is unclear.

OBJECTIVE

In this study, we set out to determine whether liver fat content (LFC), was associated with red blood cell fatty acid (RBC-FA) composition in people with type 2 diabetes.

DESIGN, SETTINGS, AND PARTICIPANTS

One hundred and sixty-two type 2 diabetic patients were included in this study. LFC was measured using (1)H-MR Spectroscopy. RBC-FA composition was measured by gas chromatography.

RESULTS

One hundred and nine (67.2%) patients had steatosis. Patients with steatosis had a higher BMI (p = 0.0005), and higher plasma triglyceride levels (p = 0.009) than did patients without steatosis. We report a significant association between palmitic acid (16:0), palmitoleic acid (16:1n-7) concentrations and ratio of monounsaturated to saturated fatty acid (palmitoleic acid to palmitic acid) and higher liver fat content. Total polyunsaturated fatty acid (PUFA), homo-gamma-linolenic acid (20:3n-6), docosahexaenoic acid (22:6n-3), and arachidonic acid (20:4 n-6) were associated with lower LFC.

CONCLUSIONS

Our data showed that an increased erythrocytes long-chain n-3 and n-6 fatty acids was associated with a lower prevalence of steatosis in patients with type 2 diabetes. These results suggest that n-3 and n-6 fatty acids supplementation could be a promising treatment for NAFLD in patients with type 2 diabetes.

Xanthogranulomatous pyelonephritis in adults: clinical and radiological findings in diffuse and focal forms

AIM

To describe the clinical and radiological features of focal and diffuse xanthogranulomatous pyelonephritis (XGP) in adults.

MATERIALS AND METHODS

A retrospective review of the clinical data, laboratory findings, imaging features, and surgical treatment of 13 cases of histologically proven XGP diagnosed between January 1993 and December 2005 was undertaken. There were 10 women and three men with a mean age of 55.2 years (range 30-87 years). All patients underwent both sonography and computed tomography (CT) of the kidneys. Magnetic resonance imaging (MRI) was performed in two patients.

RESULTS

XGP was diffuse in 11 patients and focal in two patients. Fever, anorexia and weight loss, urinary symptoms, and flank pain were the most common manifestations. Urinary tract infection was found in eight patients. Sonography and CT showed diffuse kidney enlargement in seven cases and atrophy in five cases; a solitary solid mass was found in two patients. Hydronephrosis was noted in nine cases, staghorn calculus in six, and extensive pararenal disease in six. MRI failed to provide the preoperative diagnosis in the two patients with focal XGP. Total or partial nephrectomy was performed without postoperative complications.

CONCLUSION

Although rare, XGP is the main differential diagnosis of malignant renal neoplasia. The definitive diagnosis depends on histological examination of the operative specimen. Preoperatively, the diagnosis can often be suspected based on imaging studies, primarily CT.

Diffuse xanthogranulomatous pyelonephritis with psoas abscess in a pregnant woman

We report the first case, to our knowledge, of xanthogranulomatous pyelonephritis (XGP) with psoas abscess occurring during pregnancy. A 37-year-old woman in the third trimester of pregnancy presented with low back pain and a fever. From sonographic features, a multidisciplinary team decided to perform computed tomography of the abdomen with contrast agent injection, which strongly suggested diffuse XGP of the left kidney with a psoas abscess. Cesarean section at 32 weeks was followed by extended nephrectomy. Pathological examination of the operative specimen confirmed the diagnosis. Outcomes were favorable in the mother and baby. The diagnosis and treatment of XGP during pregnancy are discussed.

Sonoanatomy of the ulnar nerve in the cubital tunnel: a multicentre study by the GEL

The objective is to determine the normal appearance of the ulnar nerve on a posterior axial sonogram section of the elbow through the medial epicondyle and the humeroulnar joint space. Ultrasound evaluation was carried out on 400 elbows with measurement of the ulnar nerve cross-sectional area and ulnar nerve-cortex distance, as well as recording of apparent ulnar nerve division. Factors that significantly influenced the study variables were sought by statistical analysis. Mean cross-sectional area of the ulnar nerve at the elbow was 7.9 +/- 3.1 mm2 overall. Values were lower in females than in males and increased between 40 and 60 years of age. The ulnar nerve-cortex distance was 0.8 +/- 0.4 mm and varied widely across individuals. Apparent ulnar nerve division at the elbow was noted in about one-fifth of individuals, with no difference between females and males or between the right and left elbows. When present, apparent division was often bilateral and was not associated with changes in cross-sectional area or in distance from the medial epicondyle cortex. This study provides normative data on ulnar nerve sonoanatomy at the elbow and establishes that apparent ulnar nerve division at the elbow is a normal variant.

Endovascular treatment as first choice in chronic intestinal ischemia

The purpose of this study was to define the place of endovascular treatment in chronic intestinal ischemia (CII). We report here a series of 19 consecutive patients treated with percutaneous angioplasty of the intestinal arteries. We excluded patients with acute ischemia, from the study. From January 1, 1989 to December 31, 2001, 19 patients with symptomatic CII were treated by endovascular techniques. This study group included 11 men and 8 women with a mean age of 59 years (range 30 to 90 years). The clinical presentation included postprandial pain in 16 patients, weight loss in 14 patients, with a mean weight loss of 7.4 kg (range 0 to 30 kg); and gastroparesis in 2 patients. Stenoses were significant in the single superior mesenteric artery (SMA) in 2 patients and in two arteries in 17 patients, including the celiac artery (CA) and SMA (n = 13), CA and inferior mesenteric artery (IMA) (n = 1), and SMA and IMA (n = 3). Balloon angioplasty was performed in only one of the arteries in each patient, 15 times in the SMA and 4 times in the CA. In 7 patients, angioplasty required stenting because of recoil (n = 5) or dissection (n = 1). In one patient the lesion was stented primarily, because of adjacent thrombus on the stenosis. Our results showed that initial treatment of CII can be endovascular. Focus on one artery only, seems to be reasonable and efficient in the short and long term.

[Sinusoidal abnormalities of the liver: MR imaging features]

This article reviews the different MR features found in sinusoidal lesions of the liver parenchyma. The diagnosis of these abnormalities is mainly based on the pathologic examination. These diagnoses relate to numerous diseases including veno-occlusive disease, Budd-Chiari disease, peliosis, hepato-portal sclerosis, and portal intra-sinusoidal thrombosis. The use of fast multi-slice acquisitions associated with dynamic enhancement of the liver leads to an efficient examination and allows analysis of both the parenchymal and vascular components of the liver.

Meckel's diverticulum and mesenterium commune in a patient with gastrointestinal bleeding

Lower gastrointestinal bleeding after aspirin intake was reported in a 64-year-old woman. Gastroscopy, colonoscopy and selective mesenteric angiography failed to reveal the source of hemorrhage; only a midgut malrotation was suggested by angiography. Small bowel enema finally demonstrated a blind sac on the antimesenteric border of the ileum, corresponding to a Meckel's diverticulum. This embryological remnant of the vitelline duct was associated with a mesenterium commune. Laparoscopy confirmed the small bowel study, and resection of the diverticulum was easily carried out. It is, to our knowledge, the first time that these developmental abnormalities have been preoperatively diagnosed together.

[Four years followup of complicated Cockett syndrome treated by iliac vein endoprosthesis]

The purpose of this study was to check the long-term patency of the left common iliac vein endoprosthesis in Cockett syndrome and to confirm this appropriate etiological treatment in complicated cases. Three patients had respectively a pulmonary embolism, left common iliac vein occlusion with protein S deficiency, and venous claudication (Paget-von Schroetter syndrome) as complications of the Cockett syndrome. Treatment with endoprosthesis was performed. A mean follow-up of 48.6 months (31-61 months) revealed a clinical improvement without any recurrence of complications. The patency of the left common iliac vein flow was maintained. Indications on this treatment are being discussed.

Percutaneous transluminal renal angioplasty in atheroma with renal failure: long-term outcomes in 99 patients

The aim of this study was to evaluate renal function changes after percutaneous transluminal renal artery angioplasty (PTRA) done to treat atheromatous renal artery stenosis with renal failure. Between 1990 and 1995, PTRA was performed in 99 renal failure patients (creatinine clearance less than 80 ml/min) with atheromatous stenosis of one or more native renal arteries. Indications for PTRA were chronic renal failure with poorly controlled hypertension (group A, 67 patients) or rapidly deteriorating renal function (group B, 32 patients). Renal function changes after PTRA were evaluated based on the percentages of patients with improved, stabilized, and worsened serum creatinine and creatinine clearance values, and on mean differences between final and baseline creatinine clearances. At the end of follow-up (19+/-10 months), group A had a significantly smaller creatinine clearance gain (42.9 ml/min before PTA to 44.5 ml/min after PTA, D=1.6 ml/min, in group A, vs 24.1-28.4 ml/min, D=4.3, in group B, p=0.03), and a significantly smaller percentage of improved patients (36 vs 62%) than group B. Most stenoses in group B either were bilateral or occurred on a solitary kidney ( p=0.001). Percutaneous transluminal renal artery angioplasty combined with aggressive medical treatment may be useful in maintaining or improving renal function, particularly in patients with a recent, sharp deterioration in renal function.

Increased cytotoxicity and stability of Lipiodol-pirarubicin emulsion compared to classical doxorubicin-Lipiodol: potential advantage for chemoembolization of unresectable hepatocellular carcinoma

There is no well-defined curative treatment for advanced and unresectable hepatocellular carcinoma. The widely used transarterial chemoembolization (TACE) with a doxorubicin-Lipiodol emulsion has not been shown to improve survival in randomized studies. Further, obstruction of the hepatic artery used in the procedure is badly tolerated in patients with cirrhosis. Drugs with a more rapid penetration into the cancer cells are likely to eliminate the need for obstruction of the hepatic artery. We therefore compared the cytotoxicity of another anthracycline pirarubicin with that of the commonly used doxorubicin. In this report, we show that pirarubicin has a greater in vitro cytotoxic effect than doxorubicin on the HepG2 and Hu-H7 human hepatoma cell lines. Pirarubicin emulsion with Lipiodol is more stable at 37 degrees C than doxorubicin-Lipiodol. Moreover, pirarubicin accumulates at a greater extent in the oil phase, permitting Lipiodol to act as a slow-releasing vector for the anthracycline. Further, amiodarone, a multidrug resistance inhibitor, was shown to decrease the intrinsic resistance of HepG2 and Hu-H7 cells to both anthracyclines, and the presence of polysorbate 80 in the amiodarone preparation increased the stability of the anthracycline-Lipiodol emulsions. We therefore conclude that pirarubicin is a better candidate for TACE than doxorubicin. The rapid and increased cytotoxicity of pirarubicin on hepatoma cancer cells and the stability of the pirarubicin-Lipiodol amiodarone emulsion could avoid the complete obstruction of the hepatic artery by Gelfoam sponges, and provide a better tolerated method of TACE in patients with latent liver insufficiency.

Hepatic arterial infusion of cisplatin diluted in hypotonic 25 g/l glucose solution administered in balloon-occluded hepatic artery: experimental rationale and clinical pilot study

Reduced osmolarity in incubation medium was previously shown to increase in vitro cellular accumulation and cytotoxicity of cisplatin on cancer cells. We confirmed in the present work that cisplatin diluted in an hypotonic 25 g/l glucose solution (124 mOsm) was dramatically more cytotoxic in vitro than cisplatin diluted in normotonic 9 g/l NaCl (300 mOsm) on the human HT29 colon and MCF7 breast cancer cells. We conducted then a pilot clinical study on the administration of cisplatin diluted in hypotonic 25 g/l glucose solution given through the balloon-occluded hepatic artery for the treatment of liver metastases from colon or breast cancer tumors. Nine patients (5 men, 4 women; mean age 58, range: 44-71) with confirmed isolated, unresectable metastases from colorectal (7) or breast (2) tumors were included in this study and a total of 23 cycles were administered (2.55 per patient; range 1-5) with an average dose of 50 mg cisplatin (range: 12.5-100). Hepatic artery dissection due to balloon injury with partial or complete arterial obstruction were encountered in 2 patients. Pain in the liver and epigastric area was the main symptom which was constant and intense during the IAH cisplatin injection. Fever > 38 degrees C was observed in 15/23 cycles and increase of creatinine in 1/23 cycles. Transient increase of hepatic transaminases without change in prothrombin time was registered in all patients. However one patient who received the highest dose of 100 mg cisplatin developed a persistent but reversible clinical jaundice and a transient increase in prothrombin time. One patient achieved a partial response (12 weeks), 7 had stable disease (mean duration: 6 weeks) and one had a progressive disease. Hepatic arterial infusion of cisplatin diluted in hypotonic 25 g/l glucose solution and administered through the balloon-occluded hepatic artery is a feasible approach. Total dose of cisplatin in hypotonic glucose solution will not exceed 80 mg by cure in a further phase II study.

Preoperative intraarterial thrombolysis before surgical revascularization for popliteal artery aneurysm with acute ischemia

Because a popliteal artery aneurysm (PAA) generates emboli that progressively deteriorate the distal arterial network, they can constitute limb-threatening lesions. In 20 to 40% of cases, discovery of PAA coincides with sudden occlusion and resulting acute ischemia. In 40 to 60% of these patients, surgical revascularization fails and amputation is required. The objective of this prospective study was to assess the value of intraarterial thrombolysis to restore distal runoff before surgical revascularization. Between January 1, 1992 and December 31, 1996, we treated 15 PAA causing acute ischemia in 15 male patients with a mean age of 66.7 years (range, 44 to 87 years). Diagnosis was documented by clinical examination and ultrasound imaging. Intraarterial thrombolysis was performed under arteriographic control through a multiperforated catheter inserted by the anterograde femoral route to the thrombus. After an initial bolus of 100,000 U of urokinase, 600,000 to 1,600,000 U was continuously infused over a period of 6 to 18 hr. Heparin sodium was administered throughout thrombolysis. Surgical revascularization was performed within 1 to 4 days (mean, 2 days) after thrombolysis by exclusion and bypass in 14 cases and percutaneous transluminal angioplasty with stenting in 1 case. The ensuing results showed that, if performed carefully, intraarterial thrombolysis can safely prepare patients presenting with occluded PAA with acute ischemia for surgical revascularization to restore distal runoff. We use this combined technique routinely in our department. Morbidity is low in comparison with the risks of amputation.

[Treatment of parathyroid adenomas with ethanol injection under ultrasonographic guidance]

STUDY OBJECTIVE

The objective of this retrospective study was to report the results of ethanol injection in parathyroid adenomas.

PATIENTS AND METHOD

Since 1988, 31 patients with inoperable primary hyperthyroidism have been treated by ultrasound-guided percutaneous ethanol injection into the adenoma. The main surgical contraindications were heart failure (n = 12) and age over 85 years (n = 11). Plasma calcium and PTH were measured 48 hours after ethanol injection and during subsequent follow-up.

RESULTS

Patients had one to three ethanol injections. With a mean 5-year follow-up, total success with normal plasma calcium and PTH levels was achieved in 20 patients (64.5%), 4 of whom underwent another ethanol injection after 1 to 3 years. Partial success with correction of plasma calcium only was achieved in 9 patients (29%) resulting in an obvious clinical benefit. Failure was observed in 2 patients (6.5%) with nodular goiter, probably due to incorrect localization of the adenoma. Treatment was always well tolerated and no major side effect was observed.

CONCLUSION

Ultrasound-guided percutaneous ethanol injection of parathyroid adenoma is effective in most cases of hyperparathyroidism and very useful in patients with a high surgical risk. The need for precise ultrasound localization of the adenoma is the main limitation of this treatment.

[Treatment of ureteropelvic junction stenosis with cold blade retrograde endopyelotomy]

BACKGROUND

The classical treatment of ureteropelvic junction (UPJ) stenosis consists of open surgical resection-anastomosis. Endopyelotomy, a less invasive procedure, allows antegrade or retrograde endoscopic incision of this junction. The authors' experience of cold blade retrograde endopyelotomy (CBRE) is presented and compared with other techniques.

MATERIAL AND METHOD

Thirteen patients (3 men and 10 women), with a mean age 55.3 years, underwent CBRE with ureteroscopic and fluoroscopic control for primary (10/13) or secondary (3/13) UPJ stenosis. The clinical and urographic efficacy of the method was assessed retrospectively.

RESULTS

Median operating times and hospital stays were 40 min and 4 days respectively. The postoperative complication rate was 15.4% (two urinary tract infections). Eleven of the 13 patients are currently symptom-free with a mean follow-up of 26.5 months. Follow-up urography (mean follow-up: 11.9 months) shows a satisfactorily revascularized junction in 84.6% of cases (1 asymptomatic stenosis, 1 symptomatic stenosis revised by open surgery).

CONCLUSION

Compared to the other treatments of UPJ stenoses, CBRE is a simple, minimally invasive technique, which reduces operating time and hospital stay and therefore presents a good cost-efficacy ratio.

Percutaneous ethanol injection into parathyroid adenomas: mid- and long-term results

The aim of this study was to evaluate mid- and long-term results of ultrasonically guided ethanol injection into parathyroid adenomas. From 1988 to 1996, 27 patients (mean age 77 +/- 13 years) were treated for parathyroid adenomas by percutaneous ethanol injection. The survey included clinical information, plasma calcium, phosphorus and PTH (1-84) evaluation. Follow-up lasted 22.6 +/- 10 months. No major complications were observed for 63 ethanol injections. Biochemical recovery was 58%, biochemical improvement at 3 months was 33%, and failure was 7%. Four of 15 cured patients presented a recurrence of the disease 1 or 2 years after the first treatment. Ultrasonically guided ethanol injection can be useful in the treatment of parathyroid adenomas when surgery is not possible. The immediate results are interesting but not as good as those obtained with surgery. A regular biochemical survey is necessary so that recurrences can be recognized and treated at an early stage.

[Subcutaneous trochanteric bursitis: an unrecognized cause of peritrochanteric pain revealed by imaging]

We present four cases of subcutanea trochanterica bursitis (one involving both sides). The bursitis was acute and inflammatory in two cases, chronic and microtraumatic in one, asymptomatic in one and septic in the last case. The acutely inflamed bursa may contain a blood effusion increasing the pain. CT and MRI provide distinctive images for the diagnosis of these particular types of periarticular diseases.

Endovascular stents in arterial injury after radiotherapy

We evaluated preliminary success and patency of stenting for the treatment of radiation-induced arterial diseases. Thirteen stents were placed in 8 patients to treat occlusion (n = 3), aneurysm (n = 1), residual stenosis (n = 2), multiple stenoses (n = 1), and delayed restenosis after previous balloon angioplasty (n = 1). Interventional procedure was successfully performed in 8 patients for their arterial lesions after radiotherapy. Six patients underwent interventional procedure once or twice. Two patients underwent PTA 4 times. Five of these patients demonstrated primary patency with relief of clinical symptoms with a mean follow-up of 2 years (range: 8-60 months). Clinical improvement was noted in the other patients. Our results suggest that stent placement by single or multiple techniques may have immediate effect on arterial lesions caused by radiation and can be considered as a therapeutic option of choice in these cases.

Papillary necrosis: a late complication of nephropathia epidemica?

In the following we describe a case of nephropathia epidemica, which exhibited, a few years after acute infection, arterial hypertension and multiple papillary necrosis. Papillary necrosis was diagnosed by i.v. pyelography and CT Scan. A complete evaluation of the patient failed to show any other etiology for medullary necrosis. If arterial hypertension has already been reported as a complication of nephropathia epidemica, papillary necrosis is exceptional, but may be explained by the severe vascular troubles engendered by Hantavirus infection in kidney medulla.

[Arteriography of the hand. Technical aspects]

Arteriography of the hand has specific indications. Digital subtraction angiography, use of pneumatic garrot to inject Buflomedyl and to create a post ischemic hyperhemia, can give an excellent arterial and venous opacification of the hand without general anesthesia. The different stages of the arteriography are examined and argued.

Percutaneous recanalization of acutely thrombosed vessels by hydrodynamic thrombectomy (Hydrolyser)

A hydrodynamic thrombectomy catheter was prospectively evaluated for the treatment of recently thrombosed vessels. A total of 52 consecutive patients (42 males and 10 females; mean age 64 +/- 15 years) presenting with acute or subacute occlusion of dialysis shunts (n = 25), peripheral bypass (n = 14) or native arteries (n = 15) were treated with the Hydrolyser (Cordis Europa NV, Roden, The Netherlands). Mean occlusion time was 4 days (range 1-17 days) and mean thrombus length 19 +/- 11 cm. The Hydrolyser was effective and fast in removing thrombus, regardless of the thrombus length. No major complications were reported. The immediate procedure success rates were 82, 100, 87 and 79 % for Brescia Cimino, dialysis shunt, native arteries and bypass grafts, respectively. Adjunctive thrombolysis (applied for persistence of residual thrombus or thrombosed distal vessels too small for hydrolytic thrombectomy) was required in 4 % of thrombotic dialysis shunts, in 20 % of native arteries and in 50 % of bypass graft occlusions. On angiographic controls, distal embolizations were reported only in native arteries (13 %) and bypasses (14 %); all were successfully treated percutaneously, except for one case treated by Fogarty balloon. Cumulative primary patency rates were respectively at 6 months 56, 62, 78 and 65 % for each indication. We conclude from this preliminary clinical study that hydrodynamic thrombectomy with a Hydrolyser is a promising technique to treat acute occlusions. This device can reduce complications as well as the time required to remove large amounts of thrombus and the use of expensive thrombolytic drugs.

[Comparison between iopamidol and ioxaglate in digital arteriography of the lower limbs]

This prospective study concerning 100 subtraction angiographies of the lower limbs compared two iodine concentrations of iopamidol (300 and 370 mg l/l) and ioxaglate (320 and 350 mg l/l). More pain and movements disturbed the subtraction with iopamidol 370 in comparison with ionic contrast media (p < 0.005). The quality of the contrast was better with ioxaglate 350 (p = 0.05) than with the others. This one appears to be a good compromise for this type of examination.

[Gastroduodenal arterial aneurysm and chronic pancreatitis. A case and review of the literature]

A case of pseudoaneurysm of the gastroduodenal artery due to chronic pancreatitis is reported. Pancreatitis causing splanchnic arterial aneurysm is more likely to affect the splenic artery than the gastroduodenal artery. Ten percent of cases of chronic pancreatitis are associated with splanchnic aneurysm. Hemorrhage occurs in 50% of cases. Color Doppler ultrasound is the best diagnostic tool, indicating the need for coeliac arteriography. In our case report, transcatheter embolization was performed with stainless steel coils and the pseudoaneurysm was successfully occluded.

[Spontaneous disappearance of herniation pit on the femoral neck]

The authors present a case of a 39 years old patient who had a herniation pit of the left femoral neck, 5 years ago. This lesion disappeared spontaneously. To our knowledge, no report of healing of a herniation pit has been previously described.

Results of ultrasonically guided percutaneous ethanol injection into parathyroid adenomas in primary hyperparathyroidism

Surgery is the usual treatment for primary hyperparathyroidism. However, some patients with high surgical risks are not suitable for surgery. For such patients, we propose, as an alternative treatment, ultrasonically guided percutaneous ethanol injection into parathyroid adenomas, in order to induce necrosis of the tumor. We report, here, the results of ultrasonically guided percutaneous ethanol injection into parathyroid adenomas, during a prolonged follow-up period up to 49 months, in a group of 13 patients (median age 79 years) with primary hyperparathyroidism and contraindications for surgery. In seven patients, complete normalization of plasma calcium, phosphorus and parathyroid hormone (PTH) levels was achieved after ethanol injections, with no recurrence of hypercalcemia during a median follow-up period of 28 months (total success). In these seven patients, plasma calcium, phosphorus and PTH levels were normalized 48 h after the successful ethanol injection. In four patients, a partial success was obtained with clinical improvement and normalization of plasma calcium levels but without complete normalization of plasma PTH levels. This partial success is due to incomplete necrosis of the adenoma, as has been confirmed in one patient by histopathological examination. The ethanol injection treatment failed in only two patients. This treatment was always well tolerated and no major side-effects were observed. In conclusion, our results give evidence that ultrasonically guided percutaneous ethanol injection into parathyroid adenomas can be a very useful alternative therapy in patients not suitable for surgery.

Primary hyperparathyroidism in very old patients

OBJECTIVES

To evaluate the clinical presentation and biological features of primary hyperparathyroidism (pHPT) in very old subjects.

METHODS

Thirty patients aged 75 years or more, with pHPT were analyzed retrospectively. The diagnosis of pHPT was based on usual biological signs and was always confirmed by the finding of morphological abnormalities with parathyroid imaging or neck surgical exploration.

RESULTS

At initial examination, recent general symptoms and neuromuscular symptoms were observed in 87% and 83% of the cases, respectively. Neuropsychiatric manifestations were noted in 73% of the cases. Confusion and depression were the most frequent findings, observed in 30% and 27% of the cases, respectively. In one of two patients with dementia like state, the mental status improved dramatically after surgery of the parathyroid adenoma. Serum calcium levels were in the normal range in 13% of the cases and equal or below 110 mg/L in 47% of the cases. There was no correlation between serum calcium level and the severity of mental changes. Serum parathyroid hormone determinations were abnormal in 93% of the patients. Thirteen patients underwent surgery with biological improvement in all cases. An ultrasonically guided percutaneous ethanol injection of parathyroid adenoma was performed in 10 patients with a biological cure rate of 50%.

CONCLUSION

This study shows the major prevalence and potential severity of neuropsychiatric disorders in pHPT in very old patients. Because neuropsychiatric disturbances can respond favourably to surgical treatment, the clinician must systematically look for pHPT in elderly patients with cognitive impairment.

[Primary sarcoma of the pulmonary artery]

On the basis of one personal case of leiomyosarcoma, the various anatomicoclinical features of sarcomas of the pulmonary artery are summed up. They most often produce a picture of severe pulmonary embolism that is resistant to all treatments; the lesion most often is a hilar mass without any associated bronchoscopic abnormality. Angiograms are not always easily interpreted, and the modern imaging techniques (ultrasound, computed tomography, and above all MRI) can best lead to the preoperative diagnosis, although this lesion is unfrequent.

[Rotatory anomaly of the lumbar spine from asymmetry of posterior articular facets (author's transl)]

Radiographs of the lumbar spine frequently demonstrate asymmetry of posterior articular facets, but this is asymptomatic in patients with good abdominal and lumbar muscles when the anomaly is only of a moderate degree. It can, however, cause rotatory instability of the subjacent vertebra leading to lumbago. It is then frequently associated with osteo-articular complications affecting the posterior arch, this being a logical consequence of a sequence of changes which can be explained by simple mechanical factors.