A Technical Report on the Performance of Percutaneous Cryoneurolysis of Splanchnic Nerves for the Treatment of Refractory Abdominal Pain in Patients with Pancreatic Cancer: Initial Experience.

PURPOSE: To report our preliminary results upon feasibility, efficacy and safety of percutaneous splanchnic nerves cryoneurolysis for the treatment of abdominal pain refractory to conservative medication in patients with pancreatic cancer MATERIALS METHODS: Institutional database research (retrospective review of prospectively collected data from April 2019 till August 2020) identified 5 patients with pancreatic cancer and pain refractory to conservative medication who underwent percutaneous cryoneurolysis of splanchnic nerves. In all patients, percutaneous cryoneurolysis was performed with posterolateral paravertebral approach using a 17 Gauge cryoprobe under computed tomography guidance and local anesthesia. Self-reported pain scores were assessed before and at the last follow-up using a pain inventory with visual analog scale (VAS) units. RESULTS: Mean patient age was 63.81 years (male-female: 3-2). Mean pain score prior to cryoanalgesia of splanchnic nerves was 9.4 VAS units. This score was reduced to a mean value of 2.6, 2.6 and 3 VAS units at 1, 3 and 6 months of follow-up, respectively. All patients reported significantly reduced analgesic usage. No complication was reported according to the CIRSE classification system. The mean procedure time was 44.4 min (range 39-50 min), including local anesthesia, cryoprobe(s) placement, ablation and post-procedural CT evaluation. CONCLUSION: Percutaneous cryoanalgesia of the splanchnic nerves is a minimally invasive, safe and effective procedure for pancreatic cancer pain relief. A larger, randomized trial is justified to substantiate these findings.

Primary adenocarcinoma of the esophagogastric junction, combined with an obscure hepatoid adenocarcinoma component, as discovered after the development of a metachronous liver metastasis.

BACKGROUND: Esophageal hepatoid adenocarcinomas (HACs) belong to alpha fetoprotein (AFP)-producing adenocarcinomas and are relatively sparse. CASE PRESENTATION: A 35-year-old man suffering from adenocarcinoma of the esophagogastric junction (EGJ), with negative preoperative studies for metastatic disease, underwent Ivor Lewis esophagectomy. The histologic examination demonstrated a poorly differentiated, IIA (T3N0M0) staged EGJ adenocarcinoma. The patient had been advised not to receive any adjuvant therapy, with the follow-up studies at six months being negative for recurrence. Eleven months postoperatively, he was diagnosed with a bulky mass in the liver's right lobe, accompanied by elevated AFP serum levels. The percutaneous biopsy revealed the presence of HAC, immunohistochemically positive for AFP. The surgical specimen was re-evaluated and was also found immunohistochemically positive for AFP, re-defining the tumor as combined adenocarcinoma and HAC of the EGJ. The patient received two sessions of transarterial chemoembolization (TACE) of the liver mass. However, following the 2nd TACE session, he developed signs of hepatic insufficiency and expired twenty days later. CONCLUSIONS: It is crucial to identify the presence of a HAC, as HAC seems to have an aggressive course, with limited therapeutic options as well as therapeutic response. HIPPOKRATIA 2020, 24(3): 138-142.

Urgent CAS for patients in high neurologic risk.

Patients with residual carotid stenosis discovered following an acute ischemic insult represent a new subset of patients eligible for early carotid intervention that may decrease the risk of recurrent stroke by new emboli and improve cerebral blood flow. Short-term clinical outcomes of patients undergoing urgent CAS appear favorable, indicating that endovascular management may be a reasonable treatment option, particularly when combined with endovascular interventions for intracranial lesions. Data on indication and complication profiles are still limited. This review focuses on current knowledge, advantages and pitfalls of urgent and/or early (up to 2 weeks) carotid stenting in those presenting with an acute neurologic event or recently symptomatic carotid stenosis.

Pancreas divisum: magnetic resonance cholangiopancreatography findings.

Pancreas divisum is a common congenital abnormality of the pancreas that results from the lack of fusion between the dorsal and ventral pancreatic ducts during foetal development. In these cases, the dorsal duct becomes the main pancreatic duct and drains most of the pancreas. Pancreas divisum is mainly asymptomatic, but the prevalence of pancreas divisum is higher in patients with chronic abdominal pain and idiopathic pancreatitis. A study of 20 patients with pancreas divisum (12 men and eight women; aged 19-77 years; mean age 39 years) and who underwent magnetic resonance cholangiopancreatography (MRCP), was performed. In our series, pancreas divisum was clinically manifested as unexplained episodes of abdominal pain (mean duration 3.2 years) (60 percent), mild pancreatitis (30 percent) or incidentally (ten percent). MRCP demonstrated non-communicating dorsal and ventral ducts, independent drainage sites, a dominant dorsal pancreatic duct, and a small cystic dilatation of the dorsal duct at minor papilla (santorinocoele). In this pictorial essay, we review the most common MRCP features of pancreas divisum.

A complicated postsurgical echinococcal cyst treated with radiofrequency ablation.

Surgery of hydatid cysts is often complicated with intrabiliary rupture (IBR), which if not recognized may lead to biliary fistula with rather high rates of morbidity and mortality. We report our experience with the application of radiofrequency (RF) ablation for the treatment of an operated hepatic echinococcal cyst which was complicated with biliocystic communication and cysteocutaneous fistula with bile leakage. RF ablation was performed under CT guidance into the remaining cyst through the cutaneous fistula. Since ablation of the cyst and the fistula the patient has been asymptomatic.

Long-term outcome of a hepatocellular carcinoma 7(1/2) years after surgery and repeated radiofrequency ablation: case report and review of the literature.

An interesting case is presented of a 78-year-old patient with cirrhosis who was managed with combined treatment (surgery and radiofrequency (RF) ablation) for hepatocellular carcinoma (HCC) and has survived for 7(1/2) years. Elevation of the alpha-FP (alpha-fetoprotein) levels was noted 2 years after surgery. CT demonstrated two lesions: one central at the remaining right liver lobe, and the other at the excision site. Biopsy of the lesions confirmed the diagnosis of HCC for both of them. RF ablation of these two lesions was performed in one session with technical success. Four and a half years after the first RF ablation a new recurrence was demonstrated at the CT follow-up control. RF ablation was again applied successfully. The imaging findings and the therapeutic percutaneous management of this patient along with the natural course of HCC and its recurrence are discussed, and the literature concerning risk factors is reviewed.

Percutaneous radiofrequency ablation of lung tumors with expandable needle electrodes: current status.

Percutaneous radiofrequency thermal ablation (RFA) has been used to treat primary and secondary liver tumors under ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI) guidance for the past decade [Park et al., Radiol Clin North Am 38:545-561, 2000; Siperstein and Gotomirski, Cancer J 6:S293-S301, 2000; Kelekis et al., Eur Radiol 13:1100-1105, 2003]. RFA is a low-cost, minimally invasive treatment that has recently attracted attention for treating tumors in different solid organs with promising results [Dupuy and Goldberg, J Vasc Interv Radiol 12:1135-1148, 2001; Friedman et al., Cardiovasc Intervent Radiol 27:427-434, 2004]. It can be provided with minimal hospitalization, and experienced practitioners have reported low complication rates [Dupuy and Goldberg, J Vasc Interv Radiol 12:1135-1148, 2001; Livraghi et al., Radiology 226:441-451, 2003]. Patients with lung malignancies (primary lung cancer or pulmonary metastases), who cannot be operated, might be candidates for RFA treatment. It can also be used in association with other treatments (i.e., chemotherapy, radiotherapy) for better disease control. Combination of the above with RFA may help reduce morbidity and mortality. Many ways to apply energy to the tumor exist (monopolar and bipolar RFA, microwave, laser, brachytherapy). In this review we will focus on expandable monopolar systems, which despite their deficiencies are the most popular in the interventional radiology sector.