Changes in the Size of a Ruptured Pheochromocytoma after Transcatheter Arterial Embolization.

The spontaneous rupture of a pheochromocytoma is rare and can be potentially fatal. We report a case of a tumor size reduction of a ruptured pheochromocytoma after transcatheter arterial embolization (TAE). A 60-year-old Japanese woman was referred to the emergency department of another hospital with a sudden onset of left lateral pain. Computed tomography of the abdomen revealed adrenal hemorrhage with a 5.7 cm adrenal mass, and she was transferred to our hospital for treatment. Considering that she had marked hypertension (193/115 mmHg), we made a provisional diagnosis of left lateral pain due to a ruptured pheochromocytoma. She underwent TAE, and the hemorrhage was successfully controlled. She was started on oral doxazosin for hypertension. The dose of doxazosin was increased to the extent that orthostatic hypotension did not develop, and blood pressure was well controlled. After discharge, the tumor size gradually decreased to approximately 1.0 cm within six months. Six months after TAE, elective laparoscopic surgery was performed, and the diagnosis was confirmed by histopathology. We observed a decrease in the size of the ruptured pheochromocytoma after TAE. To reduce the risk of laparoscopic adrenal surgery, it may be useful to monitor the size of a ruptured pheochromocytoma after TAE before deciding the surgery time.

Ice Ball Cracks on CT During Cryoablation for Renal Tumors: A Retrospective Analysis.

PURPOSE: To evaluate the frequency of ice ball cracks on CT during cryoablation of renal tumors and assess the severity of hemorrhagic complications associated with this finding. MATERIALS AND METHODS: Between March 2014 and March 2019, 130 patients underwent CT-guided cryoablation using cryoprobes with a diameter of 1.5 mm for 138 renal tumors (mean diameter, 23.6 mm; standard deviation [SD], 7.5; range, 8.3-43). Two blinded board-certified radiologists retrospectively reviewed the presence of cracks on CT obtained during the procedure. The incidence of major hemorrhage and changes in hemoglobin levels after cryoablation were examined. Factors influencing the appearance of ice ball cracks were assessed with multivariate analyses. RESULTS: Cracks were observed in 25 of the138 procedures (18%). Inter-reader reliabilities with kappa statistics were 0.90 and 0.84 for first and second freeze sessions, respectively. There were no major hemorrhagic events requiring blood transfusion or arterial embolization. Mean (± SD) decreases in hemoglobin levels between pre- and postoperative day 1 were 1.15 ± 0.86 g/dl in the cracks group and 1.01 ± 0.80 g/dl in the no cracks group with no significant difference (p = 0.14). Multivariate analyses identified a higher number of cryoprobes (odds ratio, 4.1; 95% confidence interval [CI] 1.7-11; p = 0.001) and no hydrodissection (odds ratio 6.7; 95% CI 2.1-28; p < 0.001) as factors associated with ice ball cracks. CONCLUSION: Ice ball cracks were frequently observed on CT during cryoablation for renal tumors and were seemingly self-limiting events requiring no intervention.

Ice Ball Crack During CT-Guided Renal Cryoablation Using 1.5-mm-Diameter Cryoprobes.

Ice ball fracture and massive hemorrhage are serious complications associated with renal cryoablation. When cracks occur in an ice ball, it is usually associated with adjacent renal parenchymal fracture, leading to massive hemorrhage. However, few studies have examined ice ball fracture under image-guided percutaneous renal cryoablation. We herein describe an 80-year-old male patient who had undergone CT-guided cryoablation for a left renal tumor using four cryoprobes (1.5 mm diameter each). Ice ball cracks were observed on CT images during cryoablation. However, there was no massive hemorrhage and further treatments were not necessary. This is the first report of ice ball cracks with a smaller diameter cryoprobe, which has not been considered to be associated with ice ball fracture.

Spontaneous Rupture of Renal Metastasis from Hepatocellular Carcinoma.

We report a rare life-threatening case of spontaneous rupture of renal metastasis from hepatocellular carcinoma (HCC) that was managed by emergent transcatheter arterial embolization (TAE). A 76-year-old woman diagnosed with HCC presented with acute back pain in her right side and was transferred to our hospital. Initial enhanced computed tomography revealed retroperitoneal hemorrhage from the right kidney, which was retrospectively diagnosed as a spontaneous rupture of the metastatic renal tumor from the primary HCC. Detailed examination identified an active retroperitoneal hemorrhage from the lesion and the patient's condition became hemodynamically unstable; hence emergent TAE was performed. The hospitalization period after the TAE was uneventful and sorafenib was subsequently administered. Unfortunately, two months after the TAE, the tumor locally progressed within the retroperitoneal space. Tumors were controlled by repeated TAE as the patient did not want to undergo a nephrectomy. Consequently, she survived for more than one year after emergent TAE, exhibiting low levels of tumor marker. After rupture of the metastatic renal HCC, tumors were expected to progress into the retroperitoneal space, and nephrectomy was the next possible radical treatment to offer the best chance of long-term disease control.

Preoperative lipiodol marking and its role on survival and complication rates of CT-guided cryoablation for small renal masses.

BACKGROUND: Partial nephrectomy for small renal masses (SRM) may be useful for preserving renal function, but is technically more difficult than radical nephrectomy. Cryoablation may be performed under local anesthesia. The objective of the present study is to assess the safety and therapeutic efficacy of cryoablation with lipiodol marking for SRM. METHODS: Cryoablation therapy was performed on 42 patients under local anesthesia. Their median age was 74 years (31-91). The median tumor diameter was 21 mm (10-42). Responses to the treatment were evaluated using modified Response Evaluation Criteria in Solid Tumors (mRECIST) by contrast-enhanced CT. In six patients (14.3%) for whom it was not possible to use contrast medium, plain CT findings were assessed according to Response Evaluation Criteria in Solid Tumors (RECIST). RESULTS: Twenty-nine (69%) and five (12%) patients achieved complete responses (CR) and partial responses (PR), respectively, while four (10%) and four (10%) patients each had stable disease (SD) and progressive disease (PD) after the first course of therapy. A second course of cryoablation therapy with lipiodol marking was performed on three out of four patients with PD after the first course of therapy, and resulted in a total of 32 patients achieving CR (76%). Four (36.4%) out of 11 patients for whom lipiodol marking was not conducted had PD, whereas none of the 31 patients for whom lipiodol marking was conducted had PD. All grade complications were reported in 11 (24.4%) patients while grade 3 in two (4.4%) patients. 11 (24.4%) A significant difference was observed in postoperative hemorrhagic events in all grades (18% in patients undergoing cryoablation without lipiodol marking vs. 0% in patients undergoing cryoablation without lipiodol marking). CONCLUSIONS: Although further studies involving more patients are needed in order to evaluate long-term results, cryoablation therapy appears to be a useful treatment option for SRM. Preoperative marking with lipiodol was helpful for improving complication and survival rates with cryoablation.

CT findings after lipiodol marking performed before video-assisted thoracoscopic surgery for small pulmonary nodules.

BACKGROUND: In preoperative lipiodol marking for small pulmonary nodules, lipiodol has a potential risk of distribution in the surrounding lung structure. There are no reports about the detailed accumulation and distribution of lipiodol. PURPOSE: To evaluate computed tomography (CT) findings after lipiodol marking before thoracoscopic surgery for pulmonary nodules. MATERIAL AND METHODS: Sixty-four consecutive CT-guided lipiodol markings for 103 nodules were performed in 55 patients. Lipiodol (0.2-0.4 mL) was injected using a 21-gauge needle near the nodule. The appearance of lipiodol spots was classified into the following three types on CT: type 1, dense; type 2, punctate; and type 3, unclear. The distribution of lipiodol was also investigated. Statistical analyses were performed on the accumulation and distribution related to nodule factors. Incidences of complications were also investigated. RESULTS: A total of 110 markings were performed because of seven additional procedures due to insufficient marking. All nodules were successfully resected on the same day. The appearances of the lipiodol spots were type 1 (82%), type 2 (11%), and type 3 (7.3%). The areas of distribution were lung parenchyma (54%), central bronchus (39%), peripheral bronchovascular bundle (24%), needle tract (20%), pleural space (19%), another segment of ipsilateral lung (5.5%), and contralateral lung (0.9%). Distribution into pleural space and central bronchus was frequently seen in the shallow nodules (P < 0.05). Complications were pneumothorax (61%) and pulmonary hemorrhage (35%). There were no serious symptoms. CONCLUSION: The appearance of the lipiodol spot was dense in most cases, despite frequent distribution in the surrounding lung structures without serious complications.

A case of testicular seminoma in persistent Mullerian duct syndrome with transverse testicular ectopia.

We present a rare case of testicular seminoma in persistent Mullerian duct syndrome (PMDS) with transverse testicular ectopia (TTE). A 42-year-old man noticed scrotal swelling a few weeks earlier and underwent magnetic resonance imaging (MRI) on suspicion of testicular tumor. MRI revealed a normal left testis on the left side of the left scrotum and a heterogeneous mass on the right side within the left scrotum. No right testis was found in the right scrotum. A blind-ending tubular structure with thickened wall showed a three-layer appearance on T2-weighted imaging and extended from the prostate through the left inguinal canal to the left scrotum. Findings during surgery suggested right testicular tumor associated with right TTE. The histopathological and immunohistochemical diagnoses of the testicular tumor and blind-ending tubular structure were seminoma and persistent Mullerian duct, respectively. Testicular tumor in PMDS with TTE is rare but may possess a characteristic appearance on imaging. Proper knowledge of these diseases will allow correct preoperative diagnosis.

Histological evaluation for chemotherapeutic responses of metastatic lymph nodes in gastric cancer.

AIM: To investigate the effect of preoperative chemotherapy (pre-CTx) for metastatic lymph nodes (MLNs) of gastric cancer (GC). METHODS: A retrospective cohort of patients with advanced GC, who underwent pre-CTx followed by gastrectomy, was reviewed. The histological tumor regression grade (TRG), which considered the percentage of residual cancer in the visible tumor bed, was applied to primary tumors and individual MLNs: G1a (complete response), G1b (< 10%), G2 (10%-50%) and G3 (> 50%). The clinical response to pre-CTx was retrospectively evaluated using only MLNs information, and we compared the histological and clinical evaluations of MLNs. RESULTS: Twenty-eight patients were enrolled. A total of 438 MLNs were retrieved, and 22 (5%), 48 (11%), 63 (14%) and 305 (70%) LNs were assigned as G1a, G1b, G2 and G3, respectively. Stratification of the residual MLNs based on the TRGs was as follows: 28 G1b MLNs (9%), 48 G2 MLNs (15%), and 253 G3 MLNs (76%) in the D1 region; 20 (23%), 15 (17%), and 52 (60%) in the D2 region, respectively. However, no significant correlation was found between TRGs in MLNs and clinical response in the subgroup for which evaluation of clinical response was available. CONCLUSION: Pre-CTx does not provide any outstanding histological benefit for MLNs, and an appropriate D2 lymphadenectomy should routinely be performed to offer the chance of curative resection.

Curcumin activates human glutathione S-transferase P1 expression through antioxidant response element.

Curcumin is a plant-derived diferuloylmethane compound extracted from Curcuma longa, possessing antioxidative and anticarcinogenic properties. Antioxidants and oxidative stress are known to induce the expression of certain classes of detoxification enzymes. Since the upregulation of detoxifying enzymes affects the drug metabolism and cell defense system, it is important to understand the gene regulation by such agents. In this study, we demonstrated that curcumin could induce the expression of human glutathione S-transferase P1 (GSTP1). In HepG2 cells treated with 20muM curcumin, the level of GSTP1 mRNA was significantly increased. In luciferase reporter assays, curcumin augmented the promoter activity of a reporter construct carrying 336bp upstream of the 5'-flanking region of the GSTP1 gene. Mutation analyses revealed that the region including antioxidant response element (ARE), which overlaps AP1 in sequence, was essential to the response to curcumin. While the introduction of a wild-type Nrf2 expression construct augmented the promoter activity of the GSTP1 gene, co-expression of a dominant-negative Nrf2 abolished the responsiveness to curcumin. In addition, curcumin activated the expression of the luciferase gene from a reporter construct carrying multiple ARE consensus sequences but not one with multiple AP1 sites. In a gel mobility shift assay with an oligonucleotide with GSTP1 ARE, an increase in the amount of the binding complex was observed in the nuclear extracts of curcumin-treated HepG2 cells. These results suggested that ARE is the primary sequence for the curcumin-induced transactivation of the GSTP1 gene. The induction of GSTP1 may be one of the mechanisms underlying the multiple actions of curcumin.