Summary of key guidelines for locoregional treatment of HCC in Asia, Europe, South and North America.

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide accounting for over 800,000 new cases in 2018, with the highest incidence in Asia and Africa where hepatitis B is the most common risk factor. In Europe, Japan, and the United States, hepatitis C chronic alcohol abuse and non-alcoholic fatty liver disease are more common risk factors. Five-year survival is low, less than 20% worldwide. HCC is a particularly challenging disease to treat because therapeutic options and prognosis must also consider hepatitis or cirrhosis independent of the malignancy. Locoregional therapies (LRT) including ablation, arterially directed therapy and external beam radiation are the preferred treatments for patients with good performance status, unresectable disease limited to the liver and preserved liver function. In practice, patients with portal vein tumor thrombus and limited extrahepatic disease may also be considered candidates for LRT. There are several guidelines developed by expert panels provide recommendations on treating this challenging disease including the Barcelona Clinic Liver Cancer, European Association for the Study of the Liver, European Society for Medical Oncology, American Association for the Study of the Liver Diseases, and the National Comprehensive Cancer Network. The purpose of this paper is to review the guidelines as they are applied clinically in regions with high incidence of HCC.

Performance of Ultrasonography Compared to Conventional Radiography for the Diagnosis of Osteoarthritis in Patients With Knee Pain.

Purpose: To investigate the performance of ultrasonography (US) for the detection of knee osteoarthritis (OA) in patients suffering from knee pain, compared to conventional radiographs. Methods: Cross-sectional study performed at a university teaching hospital. Consecutive patients complaining of unilateral or bilateral mechanical knee pain who signed an informed consent were included. All patients underwent simultaneously an ultrasonographic and a radiographic evaluation of the knee. Exclusion criteria were age under 18 years, prior diagnosis of knee OA, diagnosis of inflammatory arthritis, history of knee surgery or trauma, severe knee deformities, and corticosteroid injection within the last 2 months. The diagnostic properties of US for the detection of knee OA were evaluated using radiological data as the reference method. Evaluated test properties were sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the positive and negative likelihood ratio (LR+ and LR-). Results: Three-hundred twenty-two knees (281 patients) were included. Radiographic degenerative changes were present in 56.8% (183) of the evaluated knees. Regarding the diagnostic properties of the US, the presence of either osteophytes or the compromise of the femoral hyaline cartilage had the best sensitivity to detect OA (95%), with a NPV of 92% and a LR- of 0,07, while the combined identification of osteophytes and compromise of the femoral hyaline cartilage had the best specificity (94%), with 94% PPV and a LR+ of 13. Conclusion: US demonstrated an excellent sensitivity with an adequate specificity for the detection of radiographic knee OA.

Cadaveric Specimen Study of Prostate Microvasculature: Implications for Arterial Embolization.

PURPOSE: To describe the prostatic microvasculature anatomy and to measure the diameter of the intraprostatic vessels from human cadaveric specimens. MATERIAL AND METHODS: The prostates of 18 white males (35-68 years of age; mean prostate volume, 60.11 mL) were fixed in a solution of phosphate-buffered 10% formaldehyde and processed histologically with hematoxylin and eosin stain, Masson trichrome stain, immune peroxidase, and immunofluorescence. Fluorescence-conjugated antibodies (anti-CD34 and anti-actin smooth muscle) were used to mark the endothelium and the fibromuscular stroma, respectively. Each slide was digitally scanned and photographed under microscopy to measure the intraprostatic arterial diameters using image analysis software. RESULTS: In 28 hemipelvises (77.8%) a single dominant prostate artery was found (mean diameter, 1.96 mm). The microvasculature study identified 3 types of intraprostatic arterial distributions: internodal (IT), perinodal (PN), and intranodal (IN). The IT arteries are located at the trabeculae of the hyperplastic stroma between the nodules. The PN arteries were located at the periphery of each hyperplastic nodule before entering into it. The IN vessels were located inside the hyperplastic nodules as terminal arteries to the glands. The mean IT artery diameter was 317 µm (min-max range, 155-555 µm), mean PN artery diameter was 150 µm (min-max range, 59-266 µm), and the mean IN artery was 56 µm (min-max range, 24-104 µm). The diameters of intraprostatic arteries did not correlate with prostate volume (IT arteries, P = .303; PN arteries, P = .686; and IN arteries, P = .413). CONCLUSIONS: The description of the prostate microvasculature anatomy, as described by this cadaveric study, may provide useful information for prostate artery embolization.

Non-conservative Management of Placenta Accreta Spectrum in the Hybrid Operating Room: A Retrospective Cohort Study.

INTRODUCTION: Hysterectomy is the standard of care in placenta accreta spectrum (PAS). To reduce the risks of obstetric hemorrhage during surgery, endovascular interventions have been proposed. Our aim is to evaluate the feasibility and safety of the overall non-conservative management of PAS in the hybrid operating room (OR) to replace the classic two-step procedure (catheterization in the interventional radiology suite and transfer to conventional OR). MATERIALS AND METHODS: This is a retrospective study of series of patients with histopathologic confirmation of PAS treated in the hybrid OR at the same university hospital. We used for comparison our historical cohort managed with the standard two-step procedure. RESULTS: We included 110 patients, 80 in the conventional OR and 30 in the hybrid OR. There were no cases of major complications attributable to the endovascular procedures. In the two-step procedure, there were 10 (12.5%) intra-arterial catheter displacements that required repositioning in the conventional OR under mobile C-arm fluoroscopy and no cases in the hybrid OR (p = 0.04). The mean operative time was 380 + 42 min in the conventional OR and 296 + 66 min in the hybrid OR (p = .00001). There were no differences in the gestational age at delivery, postoperative length of stay, or large-volume blood transfusion. There were no maternal deaths. CONCLUSIONS: The overall non-conservative management of PAS in the hybrid OR has shown to be feasible and safe in our series, offering potential advantages to replace the classic two-step procedure. More studies are needed to evaluate whether this strategy is cost-effective and whether it may improve maternal and perinatal outcomes.

Intraoperative stent placement for the treatment of acute portal vein complications in pediatric living donor liver transplantation.

PURPOSE: Pediatric living donor liver transplantation (LDLT) in low weight recipients remains one of the most complex surgical procedures, with portal vein (PV) complications occurring in up to 19% of cases. When decreased PV flow is diagnosed intra- or perioperatively, intraoperative stent placement is a good substitute for surgical adjustment. Still, at the present moment, little is known about the technical feasibility, safety, efficacy, and long-term outcome of intraoperative stenting in LDLT. METHODS: Between 2006 and 2017, seven pediatric recipients underwent PV stent placement during the transplant or in the immediate post-operative setting. Preoperative, operative, and post-operative parameters were documented retrospectively. RESULTS: In total, nine stents were placed in seven patients. Procedures were technically successful in all patients. During the mean imaging follow-up period of 1313 days, none of the patients showed PV abnormality and PV stent remained patent throughout the post-transplant course. There were no deaths or graft loses during the follow-up period. CONCLUSIONS: Intraoperative stenting through the inferior mesenteric vein approach offers both a high feasibility and satisfactory results, with the potential for excellent long-term primary patency despite continued growth in children.

Resultado clínico del tratamiento endovascular con balón liberador de fármaco en el paciente claudicante con enfermedad femoropoplítea / Clinical Outcome of Drug-Eluting Balloon Endovascular Treatment for Femoropopliteal Lesions in Patients with Intermittent Claudication

RESUMEN Introducción: La restenosis continúa siendo el gran desafío de la terapia endovascular, por esa razón, se han desarrollado balones liberadores de fármaco (BLF) con la finalidad de reducir la restenosis. El objetivo de este trabajo es analizar los resultados de esta terapia. Material y métodos: Se realizó un análisis retrospectivo de 40 extremidades de pacientes claudicantes con lesiones femoro-poplíteas tratados con BLF. Resultados: Se obtuvo el éxito técnico en las 40 (100%) extremidades tratadas con una media de seguimiento de 11,1 mes sin evidencia de complicaciones graves relacionadas con el tratamiento con un 92,5% de las extremidades asintomáticas durante el seguimiento. En tres extremidades se realizó una nueva angioplastia por recidiva sintomática. Conclusiones: El BLF ha probado ser una herramienta útil, segura y eficaz para el tratamiento de lesiones de novo y restenosis intrastent; no obstante, en las lesiones TASC C-D se requiere la utilización de un mayor número de stents.

ABSTRACT Background: Restenosis continues to be the great challenge of endovascular therapy, and drug-eluting balloons (DEB) have been developed to reduce it. The aim of this study was to analyze the results of this therapy. Methods: A retrospective analysis of 40 limbs with femoropopliteal lesions treated with DEB was conducted in patients with intermittent claudication. Results: Technical success was obtained in the 40 (100%) limbs treated, without evidence of serious complications related with treatment, and with 92.5% of asymptomatic limbs during the follow-up period of 11.1 months. In three limbs, a new angioplasty was performed due to symptomatic recurrence. Conclusions: The drug-eluting balloon has proven to be a useful, safe and effective tool for the treatment of de novo and in-stent restenosis lesions; however, TASC C-D lesions require the use of greater number of stents.

Endovascular treatment of paravisceral mycotic aneurysm: Chimmeny endovascular sealing the end of de road.

Open surgery is the elective treatment for mycotic aneurysms of the aorta. This surgery consists of resection of the aneurysm, debridement and revascularization with an in situ or extra-anatomic bypass. Even when surgery has been successful, the morbi-mortality is raised and the endovascular treatment has become an alternative for specific patients. When mycotic aneurysms involved the visceral arteries, more complex techniques are necessary such as fenestrated endovascular aortic repair or chimmeny endovascular aortic repair and the most frequent complications of this are endoleaks and oclussion the visceral arteries. We present a case of a pacient with a paravisceral abdominal mycotic aneurysms that was result with 2 chimney technique (in the right renal and superior mesenteric arteries) and a single Nellix EVAS (Endologix, Irvine, Calif) of 12 cm long without evidence of endoleaks in the follow-up.

Stent tunnel technique to save thrombosed native hemodialysis fistula with extensive venous aneurysm.

INTRODUCTION AND PURPOSE: The increasing number of patients undergoing hemodialysis and the limited number of access sites have resulted in an increasing number of techniques to maintain vascular access for hemodialysis. Thrombosed arteriovenous (AV) fistulas with large venous aneurysms have poor treatment results, with both endovascular and surgical techniques, leading to a high rate of definitive AV access loss. The purpose of this study was to review the feasibility and initial results of this novel endovascular treatment of thrombosed AV fistulas with large venous aneurysms. MATERIALS AND METHODS: A novel endovascular treatment technique of inserting nitinol auto-expandable uncovered stents stretching through the whole puncture site area, thus creating a tunnel inside the thrombus, was retrospectively analyzed and described. RESULTS: A total of 17 stents were placed in 10 hemodialysis fistulas, with a mean venous coverage length of 17.8 cm. In all the cases, 100% technical success was achieved, with complete restoration of blood flow in all patients. There were no procedure-related complications. The mean follow-up was 167 days (range 60-420 days), with a primary and assisted patency of 80% and 100%, respectively. No multiple trans-stent struts-related complications were observed. Three stent fractures were diagnosed with plain films at the site of puncture without consequence in the venous access permeability. CONCLUSION: The "stent tunnel technique" is a feasible, safe and effective alternative to salvage native hemodialysis access, thus extending the function of the venous access with no signs of stent-related complications and a respectable midterm patency.

Resonancia magnética en el diagnóstico de amiloidosis cardíaca / Magnetic resonance imaging in the diagnosis of cardiac amyloidosis

La resonancia magnética cardíaca (RMC) es un método no invasivo que provee información acerca de la anatomía, función y caracterización tisular del miocardio, llegando a ser de gran utilidad en el diagnóstico y diferenciación de trastornos infiltrativos como la amiloidosis. La amiloidosis cardíaca (AC) es una miocardiopatía restrictiva resultado del depósito de amiloide en el corazón, que determina una semiología característica en la RM que permite establecer el diagnóstico en la mayoría de los casos. Los hallazgos por RMC incluyen hipertrofia miocárdica del ventrículo izquierdo (HVI) con realce tardío positivo en el ventrículo izquierdo (VI) y el resto de las cámaras cardíacas, asociado a alteración en la cinética del gadolinio con anulación del pool sanguíneo y hallazgos adicionales, como derrame pleural o pericárdico o ambos, que apoyan el diagnóstico1-3. Presentamos el caso de una paciente con diagnóstico de amiloidosis sometida a RMC en donde se demuestran los hallazgos característicos de esta patología. (AU)

Cardiac magnetic resonance imaging (MRI) is a noninvasive method of image that provides information about the anatomy, function and tissue characterization, becoming very useful in the diagnosis and differentiation of infiltrative disorders such as amyloidosis. Cardiac amyloidosis (CA) is a restrictive cardiomyopathy result of amyloid deposition in the heart. MRI findings include myocardial hypertrophy with positive late gadolinium enhancement (LGE) in the left ventricle (LV) associated with the altered kinetics of gadolinium and additional findings as pleural and pericardial effusion that support the diagnosis. We report the case of a patient diagnosed with amyloidosis showing the characteristic MR findings in this pathology. (AU)

Randomized controlled trial of irinotecan drug-eluting beads with simultaneous FOLFOX and bevacizumab for patients with unresectable colorectal liver-limited metastasis.

BACKGROUND: Reports have demonstrated the superior activity of combining both irinotecan and oxaliplatin (FOLFOXIRI) therapy. An option for gaining similar benefits with less toxicity would be the administration of irinotecan through a hepatic artery approach. The aim of this study was to assess the response and adverse event rates for irinotecan drug-eluting beads (DEBIRI) with folinic acid, 5-fluorouracil, and oxaliplatin (FOLFOX) and bevacizumab as a first-line treatment for unresectable colorectal liver metastasis. METHODS: Patients with colorectal liver metastases were randomly assigned to modified FOLFOX (mFOLFOX) and bevacizumab or mFOLFOX6, bevacizumab, and DEBIRI (FOLFOX-DEBIRI). The primary endpoint was the response rate. The secondary endpoints were adverse events, the rate of conversion to resection, and progression-free survival. RESULTS: The intention-to-treat population comprised 70 patients: 10 patients in the pilot and then 30 patients randomly assigned to the FOLFOX-DEBIRI arm and 30 patients randomly assigned to the FOLFOX/bevacizumab arm. The 2 groups were similar with respect to the extent of liver involvement (30% vs 30%), but a greater percentage of patients in the FOLFOX-DEBIRI arm had an Eastern Cooperative Oncology Group performance status of 1 or 2 (57% vs 31%) and extrahepatic disease (56% vs 32%, P = .02). The median numbers of chemotherapy cycles were similar (10 vs 9), and there were similar rates of grade 3/4 adverse events (54% for the FOLFOX-DEBIRI group vs 46% for the FOLFOX/bevacizumab group). The overall response rate was significantly greater in the FOLFOX-DEBIRI arm versus the FOLFOX/bevacizumab arm at 2 (78% vs 54%, P = .02), 4 (95% vs 70%, P = .03), and 6 months (76% vs 60%, P = .05). There was significantly more downsizing to resection in the FOLFOX-DEBIRI arm versus the FOLFOX/bevacizumab arm (35% vs 16%, P = .05), and there was improved median progression-free survival (15.3 vs 7.6 months). CONCLUSIONS: The simultaneous administration of mFOLFOX6 (with or without bevacizumab) and DEBIRI through the hepatic artery (FOLFOX-DEBIRI) is safe and does not cause treatment delays or increase the systemic toxicity of chemotherapy. This strategy leads to improved overall response rates, improved hepatic progression-free survival, and more durable overall progression-free survival in patients downsized to resection.

Pneumo-CT assessing response to neoadjuvant therapy in esophageal cancer: Imaging-pathological correlation.

Pneumo-computed tomography (PnCT) is a technique primarily developed and used to study stenotic lesions of the esophagus, gastroesophageal junction and stomach for pre-surgical planning. It helps to define both upper and lower borders of neoplasms located in the aforementioned areas. It achieves maximum lumen distension with CO2 highlighting thickened areas of the esophageal wall, thus allowing an accurate quantification of their extents. Although there are other alternatives for distension (oral contrast agents, water and effervescent granules), they may be suboptimal. Patients with locally advanced esophageal cancer have a dismal prognosis despite surgical resection. Therefore, neoadjuvant treatment strategies using radiation therapy and chemotherapy were developed to improve survival. Neoadjuvant therapy improves esophageal tumor prognosis in a substantial proportion of patients, and the use of imaging techniques is mandatory to detect their response. PnCT combined with virtual endoscopy and multiplanar reconstruction enhances morphologic details in esophageal cancer, and thus would allow an improved assessment of response to neoadjuvant treatment. Therefore, more information could be provided to assess the efficacy of pre-surgical treatment. We describe the potential use of PnCT to assess the response to neoadjuvant therapy in esophageal cancer with an imaging pathologic correlation.

New surgical strategy to induce liver hypertrophy: role of MDCT-volumetry to monitor and predict liver growth.

BACKGROUND/AIMS: To describe the role of MDCT-volumetry to monitor and predict liver hypertrophy in a recently introduced surgical technique in patients needing hepatectomy. METHODOLOGY: This prospective study was approved by the local research and ethics committee and patient informed consent was obtained. Twelve consecutive patients were selected for associating liver partition and portal vein ligation for staged-hepatectomy procedure. The mean absolute the future-liver-remnant (FLR) and FLR/total liver volume (TLV) ratio was calculated before and after surgery to determine the degree of hypertrophy. Six days after surgery a new CT-examination was performed to determine the FLR-volume and FLR/TLV. If the enlargement of the FLR was the expected a second-step surgery was performed. Continuous variables are expressed as mean (range). A p<0.05 was considered significant. RESULTS: The mean pre-operative FLR-volume was 402 mL and the FLR/TLV was 27%. The mean post-operative FLR-volume 6 days after the first step was 702 mL (range 521-1030 mL) being the mean difference between preoperative and postoperative FLR volume 303 mL (p<0.0001). The mean volume increase was 80% ranged from 21-139%. At day six, FLR/TLV was 46.5% (range 33.5-67.7), morbidity was 41% and mortality 0%. CONCLUSIONS: MDCT-volumetry has a key role in decision-making, monitoring and predicting liver hypertrophy pre- and postoperatively.

Síndrome de la vena cava superior en el posoperatorio inmediato de trasplante cardíaco: tratamiento endovascular / Endovascular Treatment of Superior Vena Cava Syndrome in the Immediate Postoperative Period of Heart Transplantation

El trasplante cardíaco está indicado en pacientes con insuficiencia cardíaca terminal sin opción de tratamiento médico, intervencionista o quirúrgico y puede realizarse utilizando fundamentalmente tres variantes técnicas. El beneficio de la técnica bicava en términos de parámetros hemodinámicos y clínicos la ha convertido en la más utilizada, aunque es técnicamente más demandante y puede tener algunas consecuencias, como estenosis en las anastomosis de las venas cavas. En esta presentación se describe el caso de un paciente sometido a trasplante cardíaco ortotópico con técnica bicava que en el primer día del posoperatorio desarrolló el síndrome de la vena cava superior. Durante el segundo día posoperatorio y ante sintomatología progresiva, a pesar de haberse administrado anticoagulación, se decidió realizar una flebografía diagnóstica y al mismo tiempo tratamiento endovascular. En ese procedimiento se recanalizó la vena cava superior y se implantaron tres stents autoexpandibles, con lo que se logró permeabilidad de la anastomosis entre las venas cavas donante y receptora, la vena cava superior y la subclavia derecha. La evolución fue favorable con alivio inmediato de la sintomatología. El paciente fue dado de alta sin complicaciones.

Heart transplantation is indicated in patients with end-stage heart failure who have no options with medical, interventional or surgical treatment. Among the three techniques available, the bicaval technique is the one most frequently used due to its hemodynamic and clinical benefits. However, it is technically more demanding and may have some consequences, as vena caval anastomotic stenosis. We describe the case of a patient who developed superior vena cava syndrome at postoperative day one of orthotopic heart transplantation with bicaval technique. At the second day symptoms progressed and, despite having initiated anticoagulation therapy, the patient underwent a diagnostic phlebography followed by endovascular treatment. After dilatation of the superior vena cava three self-expandable stents were implanted producing patent anastomosis between the donor and receptor venae cavae, the superior vena cava and the right subclavian vena. The patient had favorable outcomes with immediate symptoms relief and was discharged without complications.

Miomas uterinos: la embolización como alternativa a los tratamientos clásicos / Uterine myomas: embolization as alternative to traditional therapy

Los miomas uterinos sintomáticos constituyen una patología frecuente y las opciones terapéuticas clásicas son la histerectomía, la miomectomía (a cielo abierto, laparascópica o endocavitaria) y los tratamientos hormonales. Una alternativa terapéutica de reciente introducción es la embolización miomatosa que mejora los síntomas en el 90 por ciento de las pacientes y que evita los inconvenientes de una cirugía (anestesia general, transfusiones, cicatrices, etc.) permitiendo la conservación uterina. La correcta selección de pacientes y un adecuado enfoque ginecológico y endovascular son imperativos para obtener buenos resultados. Es necesario que el radiólogo general y el ecografista se familiaricen con éste nuevo tratamiento para brindar la información imagenológica y para responder a las inquietudes de sus pacientes sobre eventuales opciones terapéuticas

Miomas uterinos: la embolización como alternativa a los tratamientos clásicos / Uterine myomas: embolization as alternative to traditional therapy

Los miomas uterinos sintomáticos constituyen una patología frecuente y las opciones terapéuticas clásicas son la histerectomía, la miomectomía (a cielo abierto, laparascópica o endocavitaria) y los tratamientos hormonales. Una alternativa terapéutica de reciente introducción es la embolización miomatosa que mejora los síntomas en el 90 por ciento de las pacientes y que evita los inconvenientes de una cirugía (anestesia general, transfusiones, cicatrices, etc.) permitiendo la conservación uterina. La correcta selección de pacientes y un adecuado enfoque ginecológico y endovascular son imperativos para obtener buenos resultados. Es necesario que el radiólogo general y el ecografista se familiaricen con éste nuevo tratamiento para brindar la información imagenológica y para responder a las inquietudes de sus pacientes sobre eventuales opciones terapéuticas (AU)