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Kumar A, Acharya SK, Singh SP, Duseja A, Madan K, Shukla A, Arora A, Anand AC, Bahl A, Soin AS, Sirohi B, Dutta D, Jothimani D, Panda D, Saini G, Varghese J, Kumar K, Premkumar M, Panigrahi MK, Wadhawan M, Sahu MK, Rela M, Kalra N, Rao PN, Puri P, Bhangui P, Kar P, Shah SR, Baijal SS, Shalimar, Paul SB, Gamanagatti S, Gupta S, Taneja S, Saraswat VA, Chawla YK. 2023 Update of Indian National Association for Study of the Liver Consensus on Management of Intermediate and Advanced Hepatocellular Carcinoma: The Puri III Recommendations. J Clin Exp Hepatol 2024; 14:101269. [PMID: 38107186 PMCID: PMC10724697 DOI: 10.1016/j.jceh.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/12/2023] [Indexed: 12/19/2023] Open
Abstract
Hepatocellular carcinoma (HCC) presents significant treatment challenges despite considerable advancements in its management. The Indian National Association for the Study of the Liver (INASL) first published its guidelines to aid healthcare professionals in the diagnosis and treatment of HCC in 2014. These guidelines were subsequently updated in 2019. However, INASL has recognized the need to revise its guidelines in 2023 due to recent rapid advancements in the diagnosis and management of HCC, particularly for intermediate and advanced stages. The aim is to provide healthcare professionals with evidence-based recommendations tailored to the Indian context. To accomplish this, a task force was formed, and a two-day round table discussion was held in Puri, Odisha. During this event, experts in their respective fields deliberated and finalized consensus statements to develop these updated guidelines. The 2023 INASL guidelines offer a comprehensive framework for the diagnosis, staging, and management of intermediate and advanced HCC in India. They represent a significant step forward in standardizing clinical practices nationwide, with the primary objective of ensuring that patients with HCC receive the best possible care based on the latest evidence. The guidelines cover various topics related to intermediate and advanced HCC, including biomarkers of aggressive behavior, staging, treatment options, and follow-up care.
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Affiliation(s)
- Ashish Kumar
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110060, India
| | - Subrat K. Acharya
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, Odisha, 751 024, India
| | - Shivaram P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, Dock Road, Manglabag, Cuttack, Odisha, 753 007, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Kaushal Madan
- Clinical Hepatology, Max Hospitals, Saket, New Delhi, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GSMC & KEM Hospital, Mumbai, 400022, India
| | - Anil Arora
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110060, India
| | - Anil C. Anand
- Department of Gastroenterology, Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, Odisha, 751 024, India
| | - Ankur Bahl
- Department of Medical Oncology, Fortis Memorial Research Institute, Sector - 44, Opp. HUDA City Center, Gurugram, 122002, India
| | - Arvinder S. Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, CH Baktawar Singh Road, Sector 38, Gurugram, Haryana, 122 001, India
| | - Bhawna Sirohi
- Medical Oncology, BALCO Medical Centre, Raipur Chattisgarh, 493661, India
| | - Debnarayan Dutta
- Radiation Oncology, Amrita Institute of Medical Sciences, Ponekkara, AIMS (P.O.), Kochi, 682041, India
| | - Dinesh Jothimani
- Department of Hepatology, Dr. Rela Institute & Medical Centre, #7, CLC Works Road, Chromepet, Chennai, 600044, India
| | - Dipanjan Panda
- Department of Medical Oncology, Apollo Cancer Centre, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, 110076, India
| | - Gagan Saini
- Radiation Oncology, Max Institute of Cancer Care, Max Super-Speciality Hospital, W-3, Ashok Marg, near Radisson Blu Hotel, Sector-1, Vaishali, Ghaziabad, 201012, India
| | - Joy Varghese
- Department of Hepatology & Transplant Hepatology, Gleneagles Global Health City, 439, Cheran Nagar, Perumbakkam, Chennai, Tamil Nadu, 600100, India
| | - Karan Kumar
- Department of HPB Sciences and Liver Transplantation, Mahatma Gandhi Medical College and Hospital, RIICO Institutional Area, Sitapura, Tonk Road, Jaipur, 302022, Rajasthan, India
| | - Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Manas K. Panigrahi
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, 751019, Odisha, India
| | - Manav Wadhawan
- Liver & Digestive Diseases Institute, Institute of Liver & Digestive Diseases, BLK Max Hospital, Delhi, 110 005, India
| | - Manoj K. Sahu
- Department of Medical Gastroenterology, IMS & SUM Hospital, K8 Kalinga Nagar, Shampur, Bhubaneswar, Odisha 751 003, India
| | - Mohamed Rela
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, #7, CLC Works Road, Chromepet, Chennai, 600044, India
| | - Naveen Kalra
- Department of Radio Diagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Padaki N. Rao
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, No. 6-3-661, Punjagutta Road, Somajiguda, Hyderabad, Telangana, 500 082, India
| | - Pankaj Puri
- Fortis Escorts Liver & Digestive Diseases Institute (FELDI), Fortis Escorts Heart Institute & Research Centre, Okhla Road, New Delhi, 110025, India
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, CH Baktawar Singh Road, Sector 38, Gurugram, Haryana, 122 001, India
| | - Premashis Kar
- Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, 201 012, India
| | - Samir R. Shah
- Department of Hepatology and Liver Intensive Care, Institute of Liver Disease, HPB Surgery and Transplant Global Hospitals, Dr E Borges Road, Parel, Mumbai, 400012, India
| | - Sanjay S. Baijal
- Diagnostic and Interventional Radiology, Medanta The Medicity, CH Baktawar Singh Road, Sector 38, Gurugram, Haryana, 122 001, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Shashi B. Paul
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Shivanand Gamanagatti
- Fortis Escorts Liver & Digestive Diseases Institute (FELDI), Fortis Escorts Heart Institute & Research Centre, Okhla Road, New Delhi, 110025, India
| | - Subash Gupta
- Centre for Liver & Biliary Sciences, Liver Transplant and Biliary Sciences, Robotic Surgery, Max Super Speciality Hospital, No. 1, 2, Press Enclave Road, Mandir Marg, Saket Institutional Area, Saket, New Delhi, Delhi, 110017, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Vivek A. Saraswat
- Department of Gastroenterology and Hepatology, Mahatma Gandhi Medical College and Hospital, RIICO Institutional Area, Sitapura, Tonk Road, Jaipur, 302022, Rajasthan, India
| | - Yogesh K. Chawla
- Department of Gastroenterology, Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, Odisha, 751 024, India
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Chandola S, Dhamija E, Paul SB, Hari S, Batra A, Mathur S, Deo SVS. Imaging features of breast cancer subtypes on contrast enhanced ultrasound: a feasibility study. Ecancermedicalscience 2023; 17:1619. [PMID: 38414960 PMCID: PMC10898897 DOI: 10.3332/ecancer.2023.1619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Indexed: 02/29/2024] Open
Abstract
The objective of this research was to study the contrast enhancement patterns of the different molecular subtypes of breast cancer on contrast-enhanced ultrasound (CEUS) using both qualitative and quantitative parameters. This prospective study included females with a single breast mass which was histopathologically proven carcinoma. B mode ultrasound (USG) and CEUS were performed in all patients during baseline assessment. Qualitative CEUS assessment encompassed enhancement pattern, presence of fill-in and washout. Quantitative assessment included measurement of peak enhancement, time to peak; area under the curve and mean transit time. A p-value < 0.05 was considered statistically significant for differentiating the subtypes. The included thirty masses were categorised into two subtypes-triple negative breast cancer (TNBC) (36.7%) and non-TNBC (63.3%) subtypes. With B-mode USG, a statistically significant difference was observed between the two groups with respect to their shape and margins. TNBC lesions showed an oval shape, circumscribed margins and peripheral nodular enhancement on CEUS with the absence of fill-in even in the delayed phase (p-value - 0.04). The two subtypes did not significantly differ in terms of quantitative perfusion parameters. The various subtypes of breast cancer therefore possess distinct contrast enhancement patterns. CEUS potentially allows differentiation amongst these molecular subtypes that may aid in radiology-pathology (rad-path) correlation and follow up of the patients.
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Affiliation(s)
- Stuti Chandola
- Department of Radiodiagnosis and Interventional Radiology, IRCH, AIIMS, New Delhi 110029, India
| | - Ekta Dhamija
- Department of Radiodiagnosis and Interventional Radiology, IRCH, AIIMS, New Delhi 110029, India
| | - Shashi B Paul
- Department of Radiodiagnosis and Interventional Radiology, IRCH, AIIMS, New Delhi 110029, India
| | - Smriti Hari
- Department of Radiodiagnosis and Interventional Radiology, IRCH, AIIMS, New Delhi 110029, India
| | - Atul Batra
- Department of Medical Oncology, IRCH, AIIMS, New Delhi 110029, India
| | - Sandeep Mathur
- Department of Pathology, IRCH, AIIMS, New Delhi 110029, India
| | - S V S Deo
- Department of Surgical Oncology, IRCH, AIIMS, New Delhi 110029, India
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Paul SB, Gamanagatti SR, Dhamija E, Pulappadi VP, Shalimar, Acharya SK. Adapting the Utility of Lipiodol CT in Treating Small Hepatocellular Carcinoma. J Clin Exp Hepatol 2022; 12:664-668. [PMID: 35535096 PMCID: PMC9077192 DOI: 10.1016/j.jceh.2021.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 07/25/2021] [Indexed: 02/08/2023] Open
Abstract
Introduction Multiphase MRI liver is the gold-standard imaging modality for staging hepatocellular carcinoma (HCC) in patients with cirrhosis. Often, small HCCs diagnosed on multiphase MRI are occult on B-mode ultrasound and multiphase CT (MPCT) and thus pose a challenge for loco-regional therapy. We adapted the technique of lipiodol CT in treating two such patients of small HCC. Methods Lipiodol-CT involved an intra-arterial lipiodol injection through the hepatic artery followed by a noncontrast CT liver. CT delineated small, hyperdense, lipiodol-laden hepatic nodules, which served as a target for executing ablation of the nodule and also revealed the true disease stage by depicting the additional number of tumors in the liver. Results Case one was a 51-year female, known case of chronic hepatitis C who presented with ascites for two months. She was diagnosed with a small HCC (LI-RADS-4) in a cirrhotic liver on multiphase MRI. Percutaneous radiofrequency ablation was planned, but the mass was not located on ultrasound or multiphase CT. Lipiodol-CT was undertaken, which delineated the lipiodol-laden small HCC, which served as a target for executing ablation. Case 2 was a 55-year male, Child-Pugh A cirrhotic, who had undergone right extended hepatectomy for hepatitis B-related HCC. Follow-up MRI revealed a 5 mm segment III nodule, which had increased in size on repeat MRI at 3 months (LI-RADS-4). This nodule, too, was occult on both ultrasound and MPCT. Lipiodol CT revealed additional multiple, variable-sized lipiodol-laden nodules in the liver remnant. Treatment of trans-arterial chemoembolization was performed at one month. Both patients showed complete response to treatment. Conclusion: Lipiodol CT can be safely used in a new role of facilitating treatment of small HCCs diagnosed on MRI but occult on ultrasonography and MPCT.
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Affiliation(s)
- Shashi B. Paul
- Department of Radio-diagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India,Address for correspondence: Dr Shashi B. Paul MBBS, PhD, Scientist, Department of Radio-diagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi-110029, India. Tel: +91 11 26596223; Fax: +91 11 26588663.
| | - Shivanand R. Gamanagatti
- Department of Radio-diagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ekta Dhamija
- Department of Radio-diagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Vishnu P. Pulappadi
- Department of Radio-diagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Subrat K. Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India,Address for correspondence: Dr Shashi B. Paul MBBS, PhD, Scientist, Department of Radio-diagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi-110029, India. Tel: +91 11 26596223; Fax: +91 11 26588663.
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Kumar A, Acharya SK, Singh SP, Arora A, Dhiman RK, Aggarwal R, Anand AC, Bhangui P, Chawla YK, Datta Gupta S, Dixit VK, Duseja A, Kalra N, Kar P, Kulkarni SS, Kumar R, Kumar M, Madhavan R, Mohan Prasad V, Mukund A, Nagral A, Panda D, Paul SB, Rao PN, Rela M, Sahu MK, Saraswat VA, Shah SR, Shalimar, Sharma P, Taneja S, Wadhawan M. 2019 Update of Indian National Association for Study of the Liver Consensus on Prevention, Diagnosis, and Management of Hepatocellular Carcinoma in India: The Puri II Recommendations. J Clin Exp Hepatol 2020; 10:43-80. [PMID: 32025166 PMCID: PMC6995891 DOI: 10.1016/j.jceh.2019.09.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/15/2019] [Indexed: 01/27/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the major causes of morbidity, mortality, and healthcare expenditure in patients with chronic liver disease in India. The Indian National Association for Study of the Liver (INASL) had published its first guidelines on diagnosis and management of HCC (The Puri Recommendations) in 2014, and these guidelines were very well received by the healthcare community involved in diagnosis and management of HCC in India and neighboring countries. However, since 2014, many new developments have taken place in the field of HCC diagnosis and management, hence INASL endeavored to update its 2014 consensus guidelines. A new Task Force on HCC was constituted that reviewed the previous guidelines as well as the recent developments in various aspects of HCC that needed to be incorporated in the new guidelines. A 2-day round table discussion was held on 5th and 6th May 2018 at Puri, Odisha, to discuss, debate, and finalize the revised consensus statements. Each statement of the guideline was graded according to the Grading of Recommendations Assessment Development and Evaluation system with minor modifications. We present here the 2019 Update of INASL Consensus on Prevention, Diagnosis, and Management of Hepatocellular Carcinoma in India: The Puri-2 Recommendations.
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Key Words
- AFP, alpha-fetoprotein
- AIH, autoimmune hepatitis
- ALT, alanine aminotransferase
- DAA, direct-acting antiviral
- DALY, disability-adjusted life-year
- DNA, deoxyribonucleic acid
- GRADE, Grading of Recommendations Assessment Development and Evaluation
- Gd-BOPTA, gadolinium benzyloxypropionictetraacetate
- Gd-EOB-DTPA, gadolinium ethoxybenzyl diethylenetriamine penta-acetic acid
- HBV, hepatitis B virus
- HBeAg, hepatitis B envelope antigen
- HCC, hepatocellular carcinoma
- HIV, human immunodeficiency virus
- IARC, International Agency for Research on Cancer
- IFN, interferon
- INASL, Indian National Association for Study of the Liver
- MiRNA, micro-RNA
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steatohepatitis
- PIVKA, protein induced by vitamin K absence
- RFA
- RNA, ribonucleic acid
- SVR, sustained virological response
- TACE
- TACE, trans-arterial chemoembolization
- TARE, transarterial radioembolization
- TNF, tumor necrosis factor
- WHO, World Health Organization
- liver cancer
- targeted therapy
- transplant
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Affiliation(s)
- Ashish Kumar
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Subrat K. Acharya
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, Odisha, 751 024, India
| | - Shivaram P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, Dock Road, Manglabag, Cuttack, Odisha, 753 007, India
| | - Anil Arora
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Rakesh Aggarwal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226 014, India
| | - Anil C. Anand
- Department of Gastroenterology, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, 110 076, India
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, CH Baktawar Singh Road, Sector 38, Gurugram, Haryana, 122 001, India
| | - Yogesh K. Chawla
- Department of Gastroenterology, Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, Odisha, 751 024, India
| | - Siddhartha Datta Gupta
- Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Vinod K. Dixit
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, 221 005, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Naveen Kalra
- Department of Radio Diagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Premashish Kar
- Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, 201 012, India
| | - Suyash S. Kulkarni
- Division of Interventional Radiology, Tata Memorial Hospital, Dr. E Borges Road, Parel, Mumbai, Maharashtra, 400 012, India
| | - Rakesh Kumar
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Manoj Kumar
- Department of Hepatology, Institute of Liver & Biliary Sciences, Sector D-1, Vasant Kunj, New Delhi, 110 070, India
| | - Ram Madhavan
- Department of Radiation Oncology, Amrita Institute of Medical Sciences, Amrita University, Peeliyadu Road, Ponekkara, Edappally, Kochi, Kerala, 682 041, India
| | - V.G. Mohan Prasad
- Department of Gastroenterology, VGM Gastro Centre, 2100, Trichy Road, Rajalakshmi Mills Stop, Singanallur, Coimbatore, Tamil Nadu, 641 005, India
| | - Amar Mukund
- Department of Radiology, Institute of Liver & Biliary Sciences, Sector D-1, Vasant Kunj, New Delhi, 110 070, India
| | - Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital & Research Centre, 15, Dr Deshmukh Marg, Pedder Road, Mumbai, Maharashtra, 400 026, India
| | - Dipanjan Panda
- Department of Oncology, Institutes of Cancer, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, 110 076, India
| | - Shashi B. Paul
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Padaki N. Rao
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, No. 6-3-661, Punjagutta Road, Somajiguda, Hyderabad, Telangana, 500 082, India
| | - Mohamed Rela
- The Institute of Liver Disease & Transplantation, Gleneagles Global Health City, 439, Cheran Nagar, Perumbakkam, Chennai, Tamil Nadu, 600 100, India
| | - Manoj K. Sahu
- Department of Medical Gastroenterology, IMS & SUM Hospital, K8 Kalinga Nagar, Shampur, Bhubaneswar, Odisha 751 003, India
| | - Vivek A. Saraswat
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226 014, India
| | - Samir R. Shah
- Department of Gastroenterology, Jaslok Hospital & Research Centre, 15, Dr Deshmukh Marg, Pedder Road, Mumbai, Maharashtra, 400 026, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Praveen Sharma
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Manav Wadhawan
- Liver & Digestive Diseases Institute, Institute of Liver & Digestive Diseases, BLK Super Specialty Hospital, Delhi, 110 005, India
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Hari S, Paul SB, Vidyasagar R, Dhamija E, Adarsh AD, Thulkar S, Mathur S, Sreenivas V, Sharma S, Srivastava A, Seenu V, Prashad R. Breast mass characterization using shear wave elastography and ultrasound. Diagn Interv Imaging 2018; 99:699-707. [PMID: 30006125 DOI: 10.1016/j.diii.2018.06.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 06/08/2018] [Accepted: 06/12/2018] [Indexed: 01/27/2023]
Abstract
PURPOSE To evaluate the role of SWE in characterizing breast masses and ascertain whether additional use of SWE to ultrasound for evaluating BI-RADS 3 and 4a masses could help reduce long-term follow-up and unnecessary biopsies of these suspicious breast masses. MATERIALS AND METHODS This prospective, cross-sectional study was performed between June 2013 and November 2014. All enrolled patients underwent clinical breast examination, ultrasound, SWE and ultrasound-guided core biopsy of the breast mass. Breast Imaging Reporting and Data System (BI-RAD) categories were assigned to breast masses. For qualitative and quantitative variables of SWE, cut-off values for differentiation between benign and malignant breast masses were estimated. Modified BIRADS' (up/downgrading of BIRADS category) was done for BI-RADS 3/4a masses by combining individual SWE parameters and ultrasound findings. Sensitivity, specificity, positive and negative predictive value of modified BI-RADS' and ultrasound BI-RADS were compared. RESULTS A total of 119 women (mean age, 42.3±13.6 [SD] years; range: 13-87 years) with a single breast mass each were enrolled. Histopathologically, 57/119 (48%) breast masses were benign and 62 (52%) were malignant. On ultrasound, 42 breast masses were BI-RADS3 and 77 were BI-RADS 4 (4a, n=10; 4b, n=24; 4c, n=43) leading to 96.8% sensitivity and 70.2% specificity. On SWE, benign breast masses were oval/round, homogenous/reasonably homogenous, blue/green with lower elasticity values and malignant breast masses were irregular, inhomogeneous, red/orange with high elasticity values. On modified BI-RADS' using E-color and E-mean/E-max, specificity improved to 78.9% and 75.4% respectively. CONCLUSION Addition of SWE to ultrasound improves characterization of BI-RADS 3 and 4a masses. E-max, E-mean and E-color are the most useful SWE parameters to differentiate between malignant and benign breast masses.
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Affiliation(s)
- S Hari
- Department of Radiology, All India Institute of Medical Sciences, 110029 New Delhi, India
| | - S B Paul
- Department of Radiology, All India Institute of Medical Sciences, 110029 New Delhi, India.
| | - R Vidyasagar
- Department of Radiology, All India Institute of Medical Sciences, 110029 New Delhi, India
| | - E Dhamija
- Department of Radiology, All India Institute of Medical Sciences, 110029 New Delhi, India
| | - A D Adarsh
- Department of Radiology, All India Institute of Medical Sciences, 110029 New Delhi, India
| | - S Thulkar
- Department of Radiology, All India Institute of Medical Sciences, 110029 New Delhi, India
| | - S Mathur
- Departments of Pathology, All India Institute of Medical Sciences, 110029 New Delhi, India
| | - V Sreenivas
- Departments of Biostatistics, All India Institute of Medical Sciences, 110029 New Delhi, India
| | - S Sharma
- Department of Radiology, All India Institute of Medical Sciences, 110029 New Delhi, India
| | - A Srivastava
- Departments of Surgery, All India Institute of Medical Sciences, 110029 New Delhi, India
| | - V Seenu
- Departments of Surgery, All India Institute of Medical Sciences, 110029 New Delhi, India
| | - R Prashad
- Departments of Surgery, All India Institute of Medical Sciences, 110029 New Delhi, India
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Jain S, Gamanagatti SR, Kedia S, Thakur B, Nayak B, Kaur H, Gunjan D, Paul SB, Acharya SK. Role of Indocyanine Green in Predicting Post-Transarterial Chemoembolization Liver Failure in Hepatocellular Carcinoma. J Clin Exp Hepatol 2018; 8:28-34. [PMID: 29743794 PMCID: PMC5938326 DOI: 10.1016/j.jceh.2017.05.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Accepted: 05/15/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND/AIM Post-Transarterial Chemoembolization (TACE) Liver Failure (LF) is common in patients with Hepatocellular Carcinoma (HCC). No definitive objective parameters predict its occurrence. We assessed the role of Indocyanine Green (ICG) in prediction of post-TACE LF. METHODS Consecutive HCC patients with Child A/B class, categorized as Barcelona Clinic Liver Cancer (BCLC) staging A/B, were included between August 2012 and July 2014. All underwent ICG dynamics: Plasma Disappearance Rate (PDR) was recorded on the day of TACE. Area Under Receiver Operator Characteristic Curve (AUROC) of ICG-PDR was compared with existing prognostic scores: Model for End Stage Liver Disease (MELD), MELD-Na and Child-Turcotte-Pugh (CTP) using Hanley and McNeil method. RESULTS A total of 43 patients, mean age (±sd) 55.1 ± 12.8 years were included; 35 (81.4%) patients were males. Post-TACE LF developed after 17 (28.8%) of 59 procedures. Patients with post-TACE LF had significantly elevated baseline bilirubin (P = 0.006), alkaline phosphatase (P = 0.040) and prolonged international normalized ratio (P = 0.004). The median prognostic scores were higher in patients with post-TACE LF (CTP 7 vs 6; P < 0.001 and MELD 10.5 vs 6.3; P = 0.005). There was no difference in the MELD-Na score. ICG-PDR values were lower in those patients who developed post-TACE LF (7.4%/min vs 10.6%/min; P = 0.008). AUROC for ICG-PDR was 0.72 and a cut-off value <9.25%/min predicted the development of post-TACE LF with a sensitivity, specificity, positive predictive value and negative predictive value of 64.7%, 61.9%, 40.7% and 81.2%, respectively. There were no differences in the AUROC between ICG-PDR and other prognostic markers (Hanley and McNeil, P: 0.244-0.900). CONCLUSION ICG-PDR performs similar to MELD, MELD-Na and CTP score for predicting development of post-TACE LF.
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Affiliation(s)
- Sushil Jain
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Bhaskar Thakur
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Baibaswata Nayak
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Harpreet Kaur
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Shashi B Paul
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Subrat K Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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Paul SB, Das P, Mahanta M, Sreenivas V, Kedia S, Kalra N, Kaur H, Vijayvargiya M, Ghosh S, Gamanagatti SR, Gupta SD, Acharya SK. Assessment of liver fibrosis in chronic hepatitis: comparison of shear wave elastography and transient elastography. Abdom Radiol (NY) 2017. [PMID: 28643136 DOI: 10.1007/s00261-017-1213-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE To evaluate the diagnostic accuracy of shear wave elastography (SWE) and transient elastography (TE) in the evaluation of liver fibrosis in chronic hepatitis B (CHB) and C (CHC) patients taking liver biopsy as gold standard. METHODS Ethics committee approved this prospective cross-sectional study. Between October 2012 and December 2014, consecutive CHB/CHC patients fulfilling the inclusion criteria were included-age more than 18 years, informed written consent, willing and suitable for liver biopsy. SWE, TE, and biopsy were performed the same day. Liver stiffness measurement (LSM) cut-offs for various stages of fibrosis were generated for SWE and TE. AUC, sensitivity, specificity, and positive/negative predictive values were estimated individually or in combination. RESULTS CH patients (n = 240, CHB 172, CHC 68), 176 males, 64 females, mean age 32.6 ± 11.6 years were enrolled. Mean LSM of patients with no histological fibrosis (F0) was 5.0 ± 0.7 and 5.1+1.4 kPa on SWE and TE, respectively. For differentiating F2 and F3-4 fibrosis on SWE, at 7.0 kPa cut-off, the sensitivity was 81.3% and specificity 77.6%. For TE, at 8.3 kPa cut-off, sensitivity was 81.8% and specificity 83.1%. For F3 vs. F4, SWE sensitivity was 83.3% and specificity 90.7%. At 14.8 kPa cut-off, TE showed similar sensitivity (83.3%) but specificity increased to 96.5%. Significant correlation between SWE and TE was observed (r = 0.33, p < 0.001). On combining SWE and TE, a drop in sensitivity with increased specificity for all stages of liver fibrosis occured. CONCLUSION SWE is an accurate technique for evaluating liver fibrosis. SWE compares favorably with TE especially for predicting advanced fibrosis/cirrhosis. Combining SWE and TE further improves specificity.
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Affiliation(s)
- Shashi B Paul
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Mousumi Mahanta
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Vishnubhatla Sreenivas
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Nancy Kalra
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Harpreet Kaur
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Maneesh Vijayvargiya
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Shouriyo Ghosh
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Shivanand R Gamanagatti
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Siddhartha Dutta Gupta
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Subrat K Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110029, India
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Gunjan D, Shalimar, Nadda N, Kedia S, Nayak B, Paul SB, Gamanagatti SR, Acharya SK. Hepatocellular Carcinoma: An Unusual Complication of Longstanding Wilson Disease. J Clin Exp Hepatol 2017; 7:152-154. [PMID: 28663680 PMCID: PMC5478940 DOI: 10.1016/j.jceh.2016.09.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 09/15/2016] [Indexed: 12/12/2022] Open
Abstract
Wilson disease is caused by the accumulation of copper in the liver, brain or other organs, due to the mutation in ATP7B gene, which encodes protein that helps in excretion of copper in the bile canaliculus. Clinical presentation varies from asymptomatic elevation of transaminases to cirrhosis with decompensation. Hepatocellular carcinoma is a known complication of cirrhosis, but a rare occurrence in Wilson disease. We present a case of neurological Wilson disease, who later developed decompensated cirrhosis and hepatocellular carcinoma.
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Key Words
- ALP, alkaline phosphatise
- ALT, alanine aminotransferase
- ANA, anti-nuclear antibody
- ASMA, anti-smooth muscle antibody
- AST, aspartate aminotransferase
- Barcelona clinic liver cancer (BCLC) staging
- HCC, hepatocellular carcinoma
- MPCT, multiphasic computed tomography
- SAAG, serum-ascites albumin gradient
- TACE, trans-arterial chemo-embolization
- anti-LKM1, anti-liver kidney microsomal antibody type1
- cirrhosis
- d-penicillamine
- decompensation
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Affiliation(s)
- Deepak Gunjan
- All India Institute of Medical Sciences, New Delhi, India
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India,Address for correspondence: Dr. Shalimar, Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India. Tel.: +91 9868397211; fax: +91 11 26588641.Department of Gastroenterology, All India Institute of Medical SciencesNew DelhiIndia
| | - Neeti Nadda
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Baibaswata Nayak
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Shashi B. Paul
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | | | - Subrat K. Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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Acharya SK, Paul SB. Editorial: hepatocellular carcinoma--a rare complication of hepatic venous outflow tract obstruction---authors' reply. Aliment Pharmacol Ther 2015; 41:1213-4. [PMID: 25939465 DOI: 10.1111/apt.13209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- S K Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India. ,
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Paul SB, Shalimar, Sreenivas V, Gamanagatti SR, Sharma H, Dhamija E, Acharya SK. Incidence and risk factors of hepatocellular carcinoma in patients with hepatic venous outflow tract obstruction. Aliment Pharmacol Ther 2015; 41:961-71. [PMID: 25809735 DOI: 10.1111/apt.13173] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 02/12/2015] [Accepted: 03/03/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Frequency of hepatocellular carcinoma (HCC) in hepatic venous outflow tract obstruction (HVOTO) is unclear and risk factors in HVOTO associated with HCC are unknown. AIM To assess the incidence of HCC and to identify risk factors for HCC in primary HVOTO. METHODS In the consecutive primary HVOTO patients evaluated between 1989 to 2013, the incidence of HCC among HVOTO was assessed in a retrospective cohort study and identification of the risk factors for HCC in HVOTO patients done by a case-control study. RESULTS Of the 421 HVOTO patients, 8 had HCC at presentation (prevalence 1.9%). Another 8 of the remaining 413 developed HCC during 2076.2 person-years follow-up (mean 5.03 + 4.65 years, range 0.08-20 years). The cumulative incidence of HCC was 3.5% (95% CI 1.28-9.2%) at 10 years. The case-control study included 16 HCC as cases and remaining 405 as controls. Controls were predominantly males (M:F - 230:175), mean age 29 ± 10.3 years. Cases were predominantly females with an older age of 36.2 ± 11.4 years (P < 0.01, OR = 1.06, CI 1.0-1.10%). Presence of cirrhosis (P < 0.001), combined inferior vena cava (IVC) and hepatic vein (HV) block (P < 0.03, OR = 5.58, CI 1.43-25.30%) and long-segment IVC block (P < 0.02, OR = 6.50, CI 1.32-32.0%) were significantly higher among cases than controls. CONCLUSIONS Hepatic venous outflow tract obstruction is a risk factor for HCC. The cumulative incidence of HCC in HVOTO is low and progressively increases over time. Those with liver cirrhosis, combined IVC and HV block and long-segment IVC block are at risk to develop HCC and need active surveillance.
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Affiliation(s)
- S B Paul
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
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Abstract
Transcatheter intra-arterial therapies play a vital role in treatment of HCC due to the unique tumor vasculature. Evolution of techniques and newer efficacious modalities of tumor destruction have made these techniques popular. Various types of intra-arterial therapeutic options are currently available. These constitute: bland embolization, trans-arterial chemotherapy, trans-arterial chemo embolization with or without drug-eluting beads and trans-arterial radio embolization, which are elaborated in this review.
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Key Words
- AFP, alpha feto protein
- CR, complete response
- HAIC, hepatic artery infusion chemotherapy
- HCC, hepatocellular carcinoma
- LA, laser ablation
- OLT, orthotopic liver transplant
- PD, progressive disease
- PEI, percutaneous ethanol injection
- PR, partial response
- PVT, portal vein thrombosis
- RFA, ablation
- SD, stable disease
- TACE, trans-arterial chemoembolization
- TAE, Trans-arterial embolization
- TART, trans-arterial radiotherapy
- drug eluting bead (DEB)
- hepatocellular carcinoma (HCC)
- trans-arterial chemoembolization (TACE)
- trans-arterial embolization (TAE)
- trans-arterial radiotherapy (TART)
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Affiliation(s)
- Shashi B. Paul
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Hanish Sharma
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi 110029, India
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Kumar A, Acharya SK, Singh SP, Saraswat VA, Arora A, Duseja A, Goenka MK, Jain D, Kar P, Kumar M, Kumaran V, Mohandas KM, Panda D, Paul SB, Ramachandran J, Ramesh H, Rao PN, Shah SR, Sharma H, Thandassery RB. The Indian National Association for Study of the Liver (INASL) Consensus on Prevention, Diagnosis and Management of Hepatocellular Carcinoma in India: The Puri Recommendations. J Clin Exp Hepatol 2014; 4:S3-S26. [PMID: 25755608 PMCID: PMC4284289 DOI: 10.1016/j.jceh.2014.04.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 04/08/2014] [Indexed: 02/08/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the major causes of morbidity, mortality and healthcare expenditure in patients with chronic liver disease. There are no consensus guidelines on diagnosis and management of HCC in India. The Indian National Association for Study of the Liver (INASL) set up a Task-Force on HCC in 2011, with a mandate to develop consensus guidelines for diagnosis and management of HCC, relevant to disease patterns and clinical practices in India. The Task-Force first identified various contentious issues on various aspects of HCC and these issues were allotted to individual members of the Task-Force who reviewed them in detail. The Task-Force used the Oxford Center for Evidence Based Medicine-Levels of Evidence of 2009 for developing an evidence-based approach. A 2-day round table discussion was held on 9th and 10th February, 2013 at Puri, Odisha, to discuss, debate, and finalize the consensus statements. The members of the Task-Force reviewed and discussed the existing literature at this meeting and formulated the INASL consensus statements for each of the issues. We present here the INASL consensus guidelines (The Puri Recommendations) on prevention, diagnosis and management of HCC in India.
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Key Words
- AFP, alpha-fetoprotein
- AIIMS, All India Institute of Medical Sciences
- ASMR, age standardized mortality rate
- BCLC, Barcelona-Clinic Liver Cancer
- CEUS, contrast enhanced ultrasound
- CT, computed tomography
- DCP, des-gamma-carboxy prothrombin
- DDLT, deceased donor liver transplantation
- DE, drug eluting
- FNAC, fine needle aspiration cytology
- GPC-3, glypican-3
- GS, glutamine synthase
- Gd-EOB-DTPA, gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid
- HBV, Hepatitis B virus
- HCC, hepatocellular carcinoma
- HCV, Hepatitis C virus
- HSP-70, heat shock protein-70
- HVPG, hepatic venous pressure gradient
- ICG, indocyanine green
- ICMR, Indian Council of Medical Research
- INASL, Indian National Association for Study of the Liver
- LDLT, living donor liver transplantation
- MRI, magnetic resonance imaging
- Mabs, monoclonal antibodies
- NAFLD, non-alcoholic fatty liver disease
- OLT, orthotopic liver transplantation
- PAI, percutaneous acetic acid injection
- PEI, percutaneous ethanol injection
- PET, positron emission tomography
- PVT, portal vein thrombosis
- RECIST, Response Evaluation Criteria in Solid Tumors
- RFA
- RFA, radio frequency ablation
- SVR, sustained viral response
- TACE
- TACE, transarterial chemoembolization
- TART, trans-arterial radioisotope therapy
- UCSF, University of California San Francisco
- liver cancer
- targeted therapy
- transplant
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Affiliation(s)
- Ashish Kumar
- Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Subrat K. Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Road, New Delhi 110 029, India
| | - Shivaram P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, Odisha, India
| | - Vivek A. Saraswat
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anil Arora
- Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mahesh K. Goenka
- Department of Gastroenterology, Apollo Gleneagles Hospital, 58, Canal Circular Road, Kolkata, West Bengal 700 054, India
| | - Deepali Jain
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Premashish Kar
- Department of Medicine, Maulana Azad Medical College, University of Delhi, New Delhi, India
| | - Manoj Kumar
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Vinay Kumaran
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Kunisshery M. Mohandas
- Department of Digestive Diseases, Tata Medical Center, Kolkata, West Bengal 700156, India
| | - Dipanjan Panda
- Department of Oncology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Shashi B. Paul
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Jeyamani Ramachandran
- Department of Hepatology, Christian Medical College, Vellore, Tamil Nadu 632 004, India
| | - Hariharan Ramesh
- Department of Surgical Gastroenterology, Lakeshore Hospital and Research Center, Cochin, Kerala, India
| | - Padaki N. Rao
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Somajiguda, Hyderabad, India
| | - Samir R. Shah
- Department of Gastroenterology, Jaslok Hospital and Research Centre, Peddar Road, Mumbai, Maharashtra 400 026, India
| | - Hanish Sharma
- Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Road, New Delhi 110 029, India
| | - Ragesh B. Thandassery
- Department of Gastroenterology, Apollo Gleneagles Hospital, 58, Canal Circular Road, Kolkata, West Bengal 700 054, India
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Goyal R, Kumar A, Panda SK, Paul SB, Acharya SK. Ribavirin therapy for hepatitis E virus-induced acute on chronic liver failure: a preliminary report. Antivir Ther 2012; 17:1091-6. [PMID: 22910532 DOI: 10.3851/imp2317] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2011] [Indexed: 12/14/2022]
Abstract
Hepatitis E virus (HEV) is a common cause of acute on chronic liver failure (ACLF) in HEV hyperendemic regions with high mortality. Treatment for HEV-induced ACLF is currently not available. Recently, efficacy of ribavirin in genotype 3 chronic hepatitis E patients has been reported; however, whether ribavirin is effective in genotype 1 HEV infection is not yet known. The present study includes four patients with HEV-induced ACLF treated with ribavirin in a genotype 1 HEV hyperendemic region. Diagnosis of ACLF was made by conventional criteria and HEV as the cause of ACLF was confirmed by detection of HEV RNA by reverse transcriptase PCR. Ribavirin dose ranged from 200 to 600 mg/day and was used for a median duration of 12 (range 3-24) weeks. All patients had undetectable HEV in 3-8 weeks, survived and none had serious adverse effects. This preliminary observation from a single centre indicates that ribavirin may be an effective therapeutic agent for HEV-induced ACLF and a randomized control trial is needed to establish its efficacy.
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Affiliation(s)
- Rohit Goyal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
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Paul SB, Gamanagatti SR, Mukund A, Abbas SZ, Acharya SK. Transarterial chemoembolization for hepatocellular carcinoma: significance of extrahepatic collateral supply. Indian J Cancer 2012; 48:339-44. [PMID: 21921335 DOI: 10.4103/0019-509x.84941] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
PURPOSE Transarterial chemoemblization (TACE) is the most common treatment modality for treating patients of large unresectable hepatocellular carcinoma (HCC). Extrahepatic collateral arterial supply (ECS) to these large tumors is not uncommon. This study was designed to assess the significance and outcome of TACE in patients of HCC with ECS. MATERIALS AND METHODS A total of 85 patients of HCC of Barcelona clinic liver cancer (BCLC) stage B/C who fulfilled the following inclusion criteria--Child's A/B cirrhosis, normal main portal vein and tumor bulk involvement less than 50% of the liver-were included. TACE was done using cisplatin 100 mg, doxorubicin 50 mg and 20 ml lipiodol followed by gelfoam embolization. Presence of extrahepatic supply to the tumor was looked for in suspected cases. When the collateral supply to the mass was documented, additional chemoembolization through the extrahepatic feeding collateral was attempted. If this was unsuccessful, then the treatment was completed by percutaneous acetic acid ablation (PAI). RESULTS Eight patients showed the presence of additional extrahepatic supply to the liver tumor. The sources included inferior phrenic artery, intercostals, internal mammary artery, omental arteries, gastroduodenal artery and branch of the superior mesenteric artery. Successful chemoembolization through these collaterals was achieved in five cases and complete response was noted on follow-up. In the remaining three cases, chemoembolization could not be done and PAI was performed subsequently. CONCLUSIONS Hepatocellular carcinoma having extrahepatic collateral supply requires additional chemoembolization through the collateral to enhance the efficacy of TACE failing which an alternative locoregional therapy of percutaneous ablation may be resorted to.
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Affiliation(s)
- S B Paul
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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Paul SB, Gamanagatti SR, Aneesh MK, Acharya SK. Percutaneous ablative therapy for hepatocellular carcinoma. Natl Med J India 2011; 24:347-355. [PMID: 22680260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Shashi B Paul
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
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Das JK, Soibam R, Tiwary BK, Magdalene D, Paul SB, Bhuyan C. Orbital manifestations of Langerhans Cell Histiocytosis: A report of three cases. Oman J Ophthalmol 2011; 2:137-40. [PMID: 20927212 PMCID: PMC2903920 DOI: 10.4103/0974-620x.57315] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Langerhans Cell Histiocytosis (LCH) is a spectrum of disorders characterized by accumulation of histiocytes in various tissues. It is rarely encountered in ophthalmic practice and has an affinity for the orbit. We report three patients with LCH involving the lateral orbital wall, each with a different form of the condition.
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Affiliation(s)
- Jayanta K Das
- Department of Ophthalmology, Sri Sankaradeva Nethralaya, Guwahati
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Abstract
We report a case of embryonal orbital rhabdomyosarcoma (RMS) in a five year old boy. Immuno-histochemistry of incisional specimen confirmed diagnosis. Eight cycles of chemotherapy along with radiotherapy resulted in over 50% reduction in size of the mass. However, increase in size was noted subsequent to completion of therapy and exenteration was deemed prudent. Margins of the excised specimen were free from tumor cells, but after five months, the patient developed multiple metastases, including skeletal muscle involvement, and died nine months after exenteration, despite repeat chemotherapy along with radiotherapy. Orbital RMS with metastasis to skeletal muscle is a rare entity.
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Affiliation(s)
- Jayanta K Das
- Department of Ophthalmology, Sri Sankaradeva Nethralaya, Guwahati, India
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Paul SB, Jaganathan S, Hasan A, Dhingra R, Gamanagatti SR, Gupta AK, Acharya SK. Evaluation of hepatocellular carcinoma by contrast enhanced ultrasound: a novel technique. Trop Gastroenterol 2010; 31:213-216. [PMID: 21560527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Shashi B Paul
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
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Paul SB, Manjunatha YC, Acharya SK. Palliative treatment in advanced hepatocellular carcinoma: has it made any difference? Trop Gastroenterol 2009; 30:125-134. [PMID: 20306740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Hepatocellular carcinoma (HCC) is a global health problem, the fifth most common cancer in the world. HCC occurs in a histologically abnormal liver due to underlying chronic liver disease resulting as a sequele of the chronic viral infections, hepatitis B and C. Since these two viral infections are endemic in Asia and Africa, more than 80% of cases are encountered in these regions. In India, a large proportion of the population is "at risk" for developing chronic liver disease and, therefore, HCC. Due to the lack of screening programmes in the country, the majority of HCC patients are diagnosed at an advanced stage of the disease, thus treatment remains a challenge. Palliative therapy forms the mainstay of treatment for this group of patients. The current era provides a plethora of options for the palliative management of HCC. This review concisely summarises the historical perspective and the current status of palliative treatment in advanced HCC.
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Affiliation(s)
- Shashi B Paul
- Department of Radiodiagnosis, All India Institute of Medical Sciences New Delhi, India
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Paul SB, Chalamalasetty SB, Vishnubhatla S, Madan K, Gamanagatti SR, Batra Y, Gupta SD, Panda SK, Acharya SK. Clinical Profile, Etiology and Therapeutic Outcome in 324 Hepatocellular Carcinoma Patients at a Tertiary Care Center in India. Oncology 2009; 77:162-71. [DOI: 10.1159/000231886] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2008] [Accepted: 02/09/2009] [Indexed: 11/19/2022]
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22
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Madan K, Batra Y, Jha JK, Kumar S, Kalra N, Paul SB, Singh R, Duttagupta S, Panda SK, Acharya SK. Clinical relevance of HBV DNA load in patients with chronic hepatitis B infection. Trop Gastroenterol 2008; 29:84-90. [PMID: 18972767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Hepatitis B virus (HBV) DNA detection and quantification are now playing an increasing role in the assessment of disease activity and response to therapy. However, viraemia levels which define various stages of HBV infection have not yet been established. AIM To define viraemia levels which describe various stages of chronic hepatitis B virus infection. METHODS In a retrospective study, stored sera samples of chronic hepatitis B virus (CHB) infected patients registered at AIIMS liver clinic, from January 1996 to June 2005 were subjected to competitive, quantitative PCR analysis. RESULTS The median HBV DNA load was lowest among carriers and highest among patients with chronic hepatitis B [0 (0-8) vs. 7 (0-12) log10 copies/ml, respectively; p<0.05]. As compared to chronic hepatitis patients the DNA load was also lower among cirrhotics [7 (0-12) vs. 4.5 (0-8) log10 copies/ml, respectively; p<0.05] and hepatocellular cancer patients [ 7(0-12) vs. 0 (0-8) log10 copies/ml, respectively; p<0.05]. Patients with carriers had a DNA load which was significantly lower than e antigen negative CHB [0 (0-8) vs. 6 (0-10) log10 copies/ml; p<0.05] or e antigen positive CHB [0 (0-8) vs 8 (0-12) log10 copies/ml; p<0.05]. A threshold of 3.5 log10 copies/ml had sensitivity and specificity of 83% and 58% respectively in differentiating carriers from e antigen negative CHB. There was a strong positive correlation of HBV DNA load with inflammatory grade (R=0.334; p=0.0001), fibrosis stage (R=0.276; p=0.001) and ALT levels (R=0.378; p=0.0001). 82% (9/11) of those who lost e antigen had a decline in HBV DNA levels to <5 log10 copies/ml, whereas only 12.5% (1/8) of those who did not lose e antigen had a decline in DNA load below this level. CONCLUSIONS HBV DNA viraemia levels correlate positively with the inflammatory grade, fibrosis stage and ALT levels. Most patients who loose e antigen have a decline in DNA load to below 5 log10 copies/ml. Further prospective studies employing repeated measurements are required to define a threshold to differentiate between HBV carriers and e antigen negative CHB.
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Affiliation(s)
- K Madan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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23
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Das CJ, Paul SB, Madhusudhan KS, Gulati MS. Update in liver imaging. Trop Gastroenterol 2007; 28:149-155. [PMID: 18416343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Over the last decade, liver imaging has experienced a revolution providing a bewildering array of options for detection and characterisation of liver lesions. Cross-sectional imaging modalities like computed tomography and magnetic resonance imaging have improved in speed and resolution, thereby facilitating multiphasic scanning of the liver. The advent of the use of contrast agents for ultrasonography and magnetic resonance imaging has further paved the way for definitive diagnosis in an attempt to obviate the need for invasive diagnosis. This article captures advances made in ultrasonography, computed tomography, magnetic resonance imaging and positron emission tomography and brings the specialist up to date with the latest in liver imaging.
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Affiliation(s)
- C J Das
- Department of Radiodiagnosis, All India Institute of Medical Sciences New Delhi, India
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Affiliation(s)
- Tarun P Jain
- Department of Radiology, All India Institute of Medical Sciences, New Delhi-110029, India
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25
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Gulati GS, Gulati MS, Makharia G, Hatimota P, Saikia N, Paul SB, Acharya S. Percutaneous Glue Embolization of a Visceral Artery Pseudoaneurysm in a Case of Sickle Cell Anemia. Cardiovasc Intervent Radiol 2005; 29:665-8. [PMID: 16132392 DOI: 10.1007/s00270-004-0204-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Although aneurysmal complications of sickle cell anemia have been described in the intracranial circulation, visceral artery pseudoaneurysms in this disease entity have not previously been reported in the literature. Conventional treatment of visceral pseudoaneurysms has been surgical ligation or resection of the aneurysm. Transcatheter embolization has emerged as an attractive, minimally invasive alternative to surgery in the treatment of these lesions. In certain situations, however, due to the unfavorable angiographic anatomy precluding safe transcatheter embolization, direct percutaneous glue injection of the pseudoaneurysm sac may be considered to achieve successful occlusion of the sac. The procedure may be rendered safer by simultaneous balloon protection of the parent artery. We describe this novel treatment modality in a case of inferior pancreaticoduodenal artery pseudoaneurysm in a patient with sickle cell anemia. Although a complication in the form of glue reflux into the parent vessel occurred that necessitated surgery, this treatment modality may be used in very selected cases (where conventional endovascular embolization techniques are not applicable) after careful selection of the balloon diameter and appropriate concentration of the glue-lipiodol mixture.
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Affiliation(s)
- Gurpreet S Gulati
- Department of Cardiovascular Radiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
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Gulati MS, Srinivasan A, Paul SB, Bhatla N. Uterine restoration following fibroid expulsion after uterine artery embolisation using gelfoam. J Postgrad Med 2004; 50:80. [PMID: 15048010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
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Gulati MS, Batra Y, Paul SB, Madan K, Ahuja V, Kaul HK. Radiofrequency ablation: a new therapeutic modality for the management of hepatocellular cancer. Trop Gastroenterol 2002; 23:183-5. [PMID: 12833706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
We report two patients of hepatocellular cancer who recently underwent radiofrequency ablation at our center. Both underwent successful ablation of the tumour requiring 1-2 sessions of upto 15 minutes. There were no post procedure complications. One of the patients had developed another lesion after 10 months of follow up and underwent another session of RFA, while the second patient is doing well after one year of the procedure.
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Affiliation(s)
- M S Gulati
- Department of Radiology, All India Institute of Medical Sciences, New Delhi
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28
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Gulati MS, Paul SB, Arora NK, Mathur P, Berry M. Esophageal and gastric vasculature in children with extrahepatic portal hypertension: evaluation by intravenous CT portography. Clin Imaging 2001; 24:351-6. [PMID: 11368936 DOI: 10.1016/s0899-7071(00)00228-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE To compare the findings related to esophageal/gastric varices and congestive gastropathy on intravenous computed tomography (CT) portography (CTP) and upper gastrointestinal endoscopy (UGIE) in children with extrahepatic portal venous obstruction (EHO) presented with hematemesis. METHODS/MATERIALS Fifty pediatric patients (age < 15 years) with EHO (initially diagnosed on abdominal ultrasound) presented with hematemesis and underwent UGIE and intravenous CTP using a helical CT scanner. Axial sections of 2 mm each were obtained with a collimation of 2 mm and a table feed of 3 mm. CTP findings on these axial sections were compared with UGIE (gold standard). RESULTS The sensitivity of CTP for detection of esophageal varices, gastric varices, and gastropathy was 32/33 (97%), 38/40 (95%), and 30/32 (93%), respectively. CTP showed false positivity as well, which was 5/17 (29%), 2/10 (20%), and 13/17 (76%) for esophageal varices, gastric varices, and gastropathy, respectively. On follow-up UGIE, the endoscopic features appeared in 14/19 (74%) of false positive patients. Therefore, false positivity for all the parameters on CTP when compared to the initial UGIE represented the changes in vasculature before they were endoscopically manifest. CONCLUSIONS CTP was likely to pick up changes in esophageal and gastric vasculature earlier than UGIE in children with EHO presented with hematemesis.
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Affiliation(s)
- M S Gulati
- Department of Radiodiagnosis, All India Institute of Medical Sciences Campus, E-61, Ansari Nagar, 110 029, New Delhi, India.
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Abstract
Spinal dysraphism is a general term which encompasses a wide variety of anomalies of the spine, all of which result from imperfect midline fusion of the embryonic neural tube. This term refers to large defects that involve the spine and not to small vertical clefts commonly seen within the spinal process of L5 or S1. We present a spectrum of MR imaging findings selected from a retrospective review of 100 patients of spinal dysraphism evaluated at our institution.
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Affiliation(s)
- S Chopra
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi
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30
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Affiliation(s)
- A Batra
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
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Abstract
The authors describe the use of dual-phase intravenous CT angiography of the pelvis in two female patients, who presented with ongoing excessive vaginal bleeding, to demonstrate large adnexal and uterine arteriovenous malformations (AVMs). Power Doppler was used as the initial modality to diagnose the AVMs. CT angiography, along with 3-D rendering in the form of maximum intensity projections and shaded surface display, were especially useful for anatomical conceptualization to the gynecologist. This greatly helped in the subsequent management in the form of therapeutic embolization in both patients by reducing the time, radiation dose, and contrast required for the procedure. Subsequent surgery, which was required in both patients (due to failed embolization), was also greatly aided by the demonstration of the exact extent of the AVMs on axial CT images. Thus, CT angiography emerged as an impressive non-invasive imaging modality for the complete evaluation and management of the uterine AVMs.
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Affiliation(s)
- M S Gulati
- Department of Radiodiagnosis, All India Institute of Medical Sciences, 110 029, New Delhi, India.
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Gulati MS, Paul SB, Arora NK, Berry M. Evaluation of extrahepatic portal hypertension and surgical portal systemic shunts by intravenous CT portography. Clin Imaging 1999; 23:377-85. [PMID: 10899422 DOI: 10.1016/s0899-7071(00)00170-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The purpose of this study was to evaluate the splenoportal (SP) axis and patency of portal systemic shunts in extrahepatic portal venous obstruction (EHO) by intravenous CT portography (CTP). Fifty-five patients of preshunt EHO, and 21 patients of postshunt (surgical portal systemic shunts) EHO, were subjected to intravenous CTP on a subsecond helical CT scanner. Thin, axial sections and three dimensional (3-D) reconstructions, including maximum intensity projection (MIP) and shaded surface display (SSD), were obtained. The findings were correlated with Color Doppler Flow Imaging (CDFI). In the EHO preshunt group, the site of the block demonstrated on CTP correlated with CDFI in 53 of 55 cases. In the postshunt group, shunt patency evaluation by CTP was in agreement with CDFI in 19 of 21 patients (8 patent; 13 blocked). Two patients in each group could not be evaluated on CDFI, while CTP could provide the appropriate information. There was no false positivity or negativity with CTP in patients evaluated on both modalities. The etiology of EHO, the global view of collaterals, and the 3-D anatomy of SP axis could be well depicted and was well accepted by the surgeons. We conclude that CTP is an impressive new technique that can effectively evaluate pre- and postshunt cases of EHO.
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MESH Headings
- Adult
- Aged
- Cholestasis, Extrahepatic/complications
- Cholestasis, Extrahepatic/diagnostic imaging
- Cholestasis, Extrahepatic/surgery
- Contrast Media
- Evaluation Studies as Topic
- Female
- Humans
- Hypertension, Portal/diagnostic imaging
- Hypertension, Portal/etiology
- Hypertension, Portal/surgery
- Injections, Intravenous
- Male
- Middle Aged
- Portal Vein/diagnostic imaging
- Portasystemic Shunt, Surgical/methods
- Portography/methods
- Sensitivity and Specificity
- Tomography, X-Ray Computed/methods
- Ultrasonography, Doppler, Color
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Affiliation(s)
- M S Gulati
- Departments of Radiodiagnosis, New Delhi, India
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Gulati MS, Srivastava DN, Paul SB, Goyal M, Mitra DK, Gupta AK. Pre-operative management of congenital choledochal cyst with ultrasound-guided percutaneous choledochalcystostomy. Australas Radiol 1999; 43:514-6. [PMID: 10901969 DOI: 10.1046/j.1440-1673.1999.00722.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Choledochal cyst is a rare congenital anomaly of the biliary system, presenting in infancy. Two cases of choledochal cyst (one infected) with grossly deranged liver function tests and associated biliary atresia, which were successfully managed pre-operatively by sonoguided percutaneous choledochalcystostomy, are reported here. The use of this technique in the treatment of patients such as these is proposed.
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Affiliation(s)
- M S Gulati
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India.
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Paul SB, Mukhopadhyay S, Berry M. Low-dose urography with indigenous low osomolar contrast media. Natl Med J India 1999; 12:192-3. [PMID: 10573982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
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Abstract
Abdominal tuberculosis continues to be endemic in the developing world and has shown a resurgence in the West. Computed tomography (CT) evaluation is singularly informative as it demonstrates involvement of the bowel, peritoneum, lymph nodes, and solid organs in a single examination. A spectrum of CT findings in an immunocompetent population is presented, ranging from subtle to advanced and common to rare. Genitourinary tuberculosis and tuberculosis in AIDS are excluded as they merit separate discussions.
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Affiliation(s)
- M S Gulati
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India.
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Rosenwasser MP, Paul SB, Froimson AI. Arthroplasty of the hand and wrist. Hand Clin 1989; 5:487-505. [PMID: 2670973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The historical perspectives of the wrist and its pathologies are discussed in light of developments made by the pioneers of hand surgery.
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Affiliation(s)
- M P Rosenwasser
- Department of Orthopedic Surgery, New York Orthopedic Hospital, New York
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Abstract
This investigation describes the use of the calcium-activated protease inhibitor, leupeptin, as an adjunctive therapy to the microsurgical repair of median nerves in a primate model. Our results indicate that leupeptin facilitates morphological recovery in denervated thenar muscles and in distal sensory and mixed motor-sensory nerve trunks and functional recovery measured by motor nerve conduction velocity. Toxicological testing of leupeptin showed that, when administered at a dose of 12 mg/kg, intramuscularly, once daily, haematological and clotting profiles were not adversely affected.
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Badalamente MA, Hurst LC, Paul SB, Stracher A. Enhancement of Neuromuscular Recovery after Nerve Repair in Primates. Journal of Hand Surgery 1987; 12:211-7. [PMID: 3624979 DOI: 10.1016/0266-7681_87_90015-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
This investigation describes the use of the calcium-activated protease inhibitor, leupeptin, as an adjunctive therapy to the microsurgical repair of median nerves in a primate model. Our results indicate that leupeptin facilitates morphological recovery in denervated thenar muscles and in distal sensory and mixed motor-sensory nerve trunks and functional recovery measured by motor nerve conduction velocity. Toxicological testing of leupeptin showed that, when administered at a dose of 12mg/kg, intramuscularly, once daily, haematological and clotting profiles were not adversely affected.
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De S, Paul SB. The dogs who lived. J Indian Med Assoc 1977; 69:160. [PMID: 611153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Beerman W, Hirschfeld M, Epstein NN, Paul SB. Neurosyphilis-Its Treatment with Hyperpyrexia Produced by Diathermy. Cal West Med 1934; 40:177-184. [PMID: 18742800 PMCID: PMC1658994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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