Primary Presacral Neuroendocrine Tumor Presenting as Multiple Liver Metastasis: A Case Report.

BACKGROUND Various neoplasms, including neuroendocrine neoplasms (NENs), can arise from the presacral space. Most presacral lesions are detected due to symptoms arising from tumor growth. However, diagnosing small, asymptomatic presacral tumors is challenging because of their unique location. CASE REPORT A 63-year-old woman with chronic hepatitis C underwent follow-up after achieving a sustained virological response. Abdominal ultrasonography revealed multiple new hyperechoic masses in the liver. Physical and laboratory examinations, including tumor marker analysis, yielded unremarkable results. Computed tomography (CT) and magnetic resonance imaging (MRI) indicated metastatic liver tumors but failed to identify the primary site of these lesions. The hepatic mass was biopsied, leading to a diagnosis of grade 2 neuroendocrine tumor. 111In-pentetreotide somatostatin receptor scintigraphy revealed significant radiotracer accumulation in multiple hepatic masses, several bones, and a small presacral space lesion. Pathological examination of the presacral lesion confirmed a grade 2 neuroendocrine tumor, similar to the hepatic mass. Review of a CT scan performed 4 years earlier indicated a small cyst-like lesion in the presacral space suspected of being a developmental cyst; however, the presence of cystic components was not confirmed pathologically. The patient was diagnosed with a primary presacral neuroendocrine tumor, which might have originated from a developmental cyst, with multiple liver metastases. Chemotherapy with everolimus was initiated, and the clinical course has been uneventful. CONCLUSIONS We report a rare neuroendocrine tumor arising from the presacral space with multiple liver metastases. The presacral space should be examined when a NEN with an unknown primary site is found.

The electrical block to polyspermy induced by an intracellular Ca2+ increase at fertilization of the clawed frogs, Xenopus laevis and Xenopus tropicalis.

Polyspermy blocking, to ensure monospermic fertilization, is necessary for normal diploid development in most animals. We have demonstrated here that monospermy in the clawed frog, Xenopus tropicalis, as well as in X. laevis, is ensured by a fast, electrical block to polyspermy on the egg plasma membrane after the entry of the first sperm, which is mediated by the positive-going fertilization potential. An intracellular Ca2+ concentration ([Ca2+ ]i ) at the sperm entry site was propagated as a Ca2+ wave over the whole egg cytoplasm. In the X. tropicalis eggs fertilized in 10% Steinberg's solution, the positive-going fertilization potential of +27 mV was generated by opening of Ca2+ -activated Cl- -channels (CaCCs). The fertilization was completely inhibited when the egg's membrane potential was clamped at +10 mV and 0 mV in X. tropicalis and X. laevis, respectively. In X. tropicalis, a small number of eggs were fertilized at 0 mV. In the eggs whose membrane potential was clamped below -10 mV, a large increase in inward current, the fertilization current, was recorded and allowed polyspermy to occur. A small initial step-like current (IS current) was observed at the beginning of the increase in the fertilization current. As the IS current was elicited soon after a small increase in [Ca2+ ]i , this is probably mediated by the opening of CaCCs. This study not only characterized the fast and electrical polyspermy in X. tropicalis, but also explained that the initial phase of [Ca2+ ]i increase causes IS current during the early phase of egg activation of Xenopus fertilization.

HCC-to-liver contrast on arterial-dominant phase images of EOB-enhanced MRI: comparison with dynamic CT.

The purpose of this study was to assess the efficacy of arterial-dominant phase images of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (EOB)-enhanced magnetic resonance imaging (MRI) for evaluation of arterial blood supply in hepatocellular carcinoma (HCC) in comparison with that of multiphasic dynamic computed tomography (CT). This study comprised 30 patients (22 men and 8 women, mean age: 68.0 years) with 40 pathologically proven HCCs (well differentiated: 3, moderately differentiated: 30, poorly differentiated: 7, mean diameter: 45.1 mm), all of whom underwent EOB-enhanced MRI and dynamic CT preoperative assessment. Regions of interest were placed over HCCs and the adjacent normal liver, and signal intensities or CT values were measured by two experienced abdominal radiologists on the arterial-dominant phase images of EOB-enhanced MRI and dynamic CT images. HCC-to-liver contrasts [Michelson's contrast: C(M)=(S(HCC)-S(Liver))/(S(HCC)+S(Liver))] were calculated and compared among the modalities. HCC-to-liver contrasts were also visually scored on a 5-point scale and compared. The mean C(M) and visual score for dynamic CT were significantly higher than those for EOB-enhanced MRI. Good agreements were obtained among the two observers. Dynamic CT is a more suitable modality than EOB-enhanced MRI for evaluation of arterial blood supply in HCC. This should be taken into account for diagnosis and management of HCC.

Is embolization of the pancreas safe? Pancreatic histological changes after selective transcatheter arterial embolization with N-butyl cyanoacrylate in a swine model.

PURPOSE: This study was designed to evaluate the safety of selective transcatheter arterial embolization (TAE) with N-butyl cyanoacrylate (NBCA) in a swine model in terms of histological changes in the pancreas. METHODS: Three groups of two female swine (58-64 kg) per group underwent TAE of the dorsal pancreatic artery, under anesthesia, with 1:1, 1:4, and 1:9 mixtures of NBCA and iodized oil. Blood parameters were evaluated at days 1, 4, and 10 after TAE, after which the animals were sacrificed and pancreatic tissues were examined under light microscopy. RESULTS: All of the animals were asymptomatic and survived for 10 days. Cone beam computed tomographic angiography revealed occlusion of the dorsal pancreatic artery and no enhancement in the embolized area. The white blood cell count and C-reactive protein level were elevated slightly on day 1 after TAE (mean ± SD: 252.7 ± 27.8 × 10(2)/µl and 0.15 ± 0.07 mg/l, respectively), but they normalized or remained near the upper normal limit thereafter. The serum amylase and lipase levels also were elevated on day 1 (8831.7 ± 2169.2 U/l and 130 ± 53.4 U/l, respectively) but normalized thereafter. Histologically, necrosis and fibrosis were noted only in the embolized segment, and necrosis and acute inflammatory reactions were absent in the nonembolized segment. The border between both segments was well defined. Lymphocytic infiltration and foreign body reaction were noted around the embolized vessels. CONCLUSIONS: Selective TAE with NBCA in the pancreas caused localized ischemic necrosis without clinically significant pancreatitis; therefore, this procedure is tolerable in swine.

N-butyl cyanoacrylate embolization for pseudoaneurysms complicating pancreatitis or pancreatectomy.

PURPOSE: To evaluate the clinical effectiveness and safety of transcatheter arterial embolization with n-butyl cyanoacrylate (NBCA) for pseudoaneurysms complicating pancreatitis or pancreatectomy. MATERIALS AND METHODS: Twelve procedures were performed in nine patients (seven men and two women; mean age, 60.6 years) for pseudoaneurysms that occurred secondary to pancreatitis or as a consequence of pancreatic juice leakage at the site of pancreatectomy. For embolization, NBCA was mixed with iodized oil at a ratio of 1:1-1:4; in one patient with failed selective catheterization of the target vessel, the mixture ratio was 1:9. Technical and clinical success rates, recurrent bleeding, procedural complications, serum amylase level, and clinical outcome were determined for each procedure. RESULTS: Embolization was technically successful in all procedures, with no recurrent bleeding documented from the initially treated territory. In three procedures, we encountered additional bleeding vessels at 11, 33, and 49 days after the procedures, which were successfully managed by a second embolization in each case. There were no major complications related to the procedures. As minor complications, in two procedures, the embolized material overflowed beyond the target vessels; however, no clinically significant ischemic events were observed in the embolized territories. Serum amylase did not increase compared with initial levels after any of the procedures. Seven patients were discharged after clinical improvement. Two patients died 2 and 3 weeks after the embolization as a result of multiple organ failure not associated with the procedure. CONCLUSIONS: In this limited series, NBCA embolization was found to be feasible and effective for pseudoaneurysms as a complication of pancreatitis or pancreatectomy.

Percutaneous selective embolectomy using a Fogarty Thru-Lumen Catheter for pancreas graft thrombosis: a case report.

A 57-year-old woman with a history of diabetes mellitus underwent simultaneous pancreas-kidney transplantation. The pancreaticoduodenal graft was implanted in the right iliac fossa. The donor's portal vein was anastomosed to the recipient's inferior vena cava (IVC). Seven days after the surgery, a thrombus was detected in the graft veins. Percutaneous thrombolysis was immediately performed; however, venous congestion was still present. We therefore attempted selective embolectomy using a Fogarty Thru-Lumen Catheter. Thrombi were directed from the graft veins toward the IVC and captured in the IVC filter with complete elimination of the thrombus without any major complications. We present our technique for the successful treatment of pancreas graft thrombosis within a short time period by percutaneous selective embolectomy using a Fogarty Thru-Lumen Catheter.

Bleeding duodenal varices successfully treated with balloon-occluded retrograde transvenous obliteration (B-RTO) assisted by CT during arterial portography.

A 60-year-old woman with massive hemorrhage from duodenal varices was transferred to our hospital for the purpose of transcatheter intervention. Although digital subtraction arterial portography could not depict the entire pathway of collateral circulation, the efferent route of the duodenal varices was clearly demonstrated on subsequent CT during arterial portography. Balloon-occluded retrograde transvenous obliteration (B-RTO) of the varices was performed via the efferent vein and achieved complete thrombosis of the varices.

Endovascular obliteration of bleeding duodenal varices in patients with liver cirrhosis.

The purpose of this paper is to describe our experience with endovascular obliteration of duodenal varices in patients with liver cirrhosis and portal hypertension. Balloon-occluded transvenous retrograde and percutaneous transhepatic anterograde embolizations were performed for duodenal varices in five patients with liver cirrhosis, portal hypertension, and decreased liver function. All patients had undergone previous endoscopic treatments that failed to stop bleeding and were poor surgical candidates. Temporary balloon occlusion catheters were used to achieve accumulation of an ethanolamine oleate-iopamidol mixture inside the varices. Elimination of the varices was successful in all patients. Retrograde transvenous obliteration via efferent veins to the inferior vena cava was enough to achieve adequate sclerosant accumulation in three patients. A combined anterograde-retrograde embolization was used in one patient with balloon occlusion of afferent and efferent veins. Transhepatic embolization through the afferent vein was performed in one patient under balloon occlusion of both efferent and afferent veins. There was complete variceal thrombosis and no bleeding was observed at follow-up. No major complications were recorded. Endovascular obliteration of duodenal varices is a feasible and safe alternative procedure for managing patients with portal hypertension and hemorrhage from this source.

Use of the wallstent for symptomatic relief of malignant inferior vena cava obstructions.

PURPOSE: To report our experience with the Wallstent for the relief of congestive symptoms in patients with malignant inferior vena cava (IVC) obstructions. MATERIALS AND METHODS: We treated five patients with malignant obstructions of the IVC with a total of seven self-expandable stents. All obstructions were due to extrinsic compression; the procedures were indicated to relieve congestive symptoms in patients unresponsive to other therapies or in whom other treatments were contraindicated. Patients were evaluated for decrease in ascites and edema, weight loss, and patency, where available. RESULTS: All procedures were straightforward and obstructions could be successfully canalized. Inferior venacavograms obtained immediately after the procedure showed complete revascularization and disappearance of collateral circulation. Follow-up was carried out until death in four patients and until discharge in one. Of the five patients, four showed clinical improvement and one had no improvement. There was no recurrence of congestive symptoms. Except for one patient with partial migration of a stent, there were no important complications related to the procedure. CONCLUSION: Wallstents could be placed without complications in the IVC and were effective to ameliorate congestive symptoms in patients with malignant IVC obstructions.

Portosplenic blood flow separation in a patient with portosystemic encephalopathy and a spontaneous splenorenal shunt.

A patient with portosystemic encephalopathy, hyperammonemia, and a spontaneous splenorenal shunt was admitted to the authors' institution after a failed attempt at transvenous retrograde shunt obliteration. As an alternative approach, the authors separated splenic and portal flows by embolizing only the proximal splenic vein while leaving the shunt intact. Thus, the splenic flow could escape into the systemic circulation and an extreme increase in portal pressure was avoided. The procedure could provide rapid decreases in blood ammonia levels and a fast resolution of symptoms, but repeated interventions were required.

Transcatheter arterial embolization for advanced tumor thrombus with marked arterioportal or arteriovenous shunt complicating hepatocellular carcinoma.

PURPOSE: To evaluate the efficacy and safety of transcatheter arterial embolization with gelatin sponge immersed in an anti-cancer agent (GIA-TAE) alone or combined with radiation therapy, in hepatocellular carcinoma with portal vein tumor thrombus (PVTT) or hepatic vein tumor thrombus (HVTT) complicated by marked arterioportal or arteriovenous shunts. MATERIALS AND METHODS: GIA-TAE was performed in 15 patients with PVTT and arterioportal shunts to the main portal trunk or first-order branch, and five with HVTT and arteriovenous shunts, adding radiation therapy in suitable cases. Primary efficacy, hemodynamic changes, Child-Pugh score, and survival rates were evaluated. RESULTS: GIA-TAE with or without radiation therapy was effective for tumor thrombus in 11 patients with PVTT and in four with HVTT. Treatment was effective for the main tumor in eight patients with PVTT and three with HVTT. Shunts disappeared in seven of 13 patients available for follow-up. Child-Pugh scores before and after the treatment were not significantly different. Median survival times of PVTT and HVTT groups were 8.7 and 12.2 months, respectively. One-year survival rates for both groups were about 15.6% and 50.0%, respectively. CONCLUSION: TAE with GIA alone or combined with radiation therapy is effective and safe for severe arteriovenous shunts with PVTT or HVTT, and also favors patient survival.

Renal arteriovenous fistula with rapid blood flow successfully treated by transcatheter arterial embolization: application of interlocking detachable coil as coil anchor.

A 70-year-old woman presented to our outpatient clinic with a large idiopathic renal arteriovenous fistula (AVF). Transcatheter arterial embolization (TAE) using interlocking detachable coils (IDC) as an anchor was planned. However, because of markedly rapid blood flow and excessive coil flexibility, detaching an IDC carried a high risk of migration. Therefore, we first coiled multiple loops of a microcatheter and then loaded it with an IDC. In this way, the coil was well fitted to the arterial wall and could be detached by withdrawing the microcatheter during balloon occlusion ("pre-framing technique"). Complete occlusion of the afferent artery was achieved by additional coiling and absolute ethanol. This technique contributed to a safe embolization of a high-flow AVF, avoiding migration of the IDC.

Application of balloon-occluded retrograde transvenous obliteration to gastric varices complicating refractory ascites.

We report two cases of gastric varices complicated by massive ascites that disappeared after balloon-occluded retrograde transvenous obliteration (B-RTO). The first patient had progressive gastric varices that continued to enlarge even after three episodes of esophagogastric variceal bleeding, and the second patient was admitted to our hospital because of the bleeding from gastric varices. After B-RTO procedures in both patients, significant improvement of the ascites, hepatic function reserve, and hypoalbuminemia was observed. Although further experience is needed, our experience points to the likelihood of the amelioration of ascites after B-RTO.

Prophylactic stenting of the inferior vena cava before transcatheter embolization of renal cell carcinomas: an alternative to filter placement.

PURPOSE: To report the use of the self-expanding Wallstent as an alternative to prophylactic inferior vena cava (IVC) filter placement before embolization of renal carcinomas with tumor thrombus. CASE REPORTS: Two patients, a 71-year-old man and an 88-year-old woman, were diagnosed with extensive tumor infiltration of the IVC secondary to renal cell carcinomas. Prophylactic placement of an IVC filter before transcatheter embolization was unsuccessful in both cases; a reduced space for deployment would have left part of the filter inside the right atrium. Instead, a Wallstent was used to constrain the tumor thrombus against the vessel wall and, at the same time, protect the patency of the contralateral kidney. Adequate patencies were confirmed 9 months after stenting in the first patient and after 19 days in the second patient. There were no clinical manifestations of pulmonary embolism. CONCLUSIONS: Wallstent implantation is an alternative prophylactic measure before transarterial embolization of renal carcinomas if IVC filters cannot be placed.

Prospective trial of combined transcatheter arterial chemoembolization and three-dimensional conformal radiotherapy for portal vein tumor thrombus in patients with unresectable hepatocellular carcinoma.

PURPOSE: We conducted a prospective trial of combined transarterial chemoembolization (TACE) and three-dimensional conformal radiotherapy (3D-CRT) for portal vein tumor thrombus (PVTT) in unresectable hepatocellular carcinoma (HCC). The aim of the present study was to investigate the efficacy and toxicity of this trial regime. METHODS AND MATERIALS: Patients with unresectable HCC complicated with tumor thrombus in the first branch of portal vein were selected as eligible for this study. TACE was performed using Lipiodol, epirubicin hydrochloride, and mitomycin, followed by gelatin sponge cubes. The 3D-CRT was performed targeting the clinical target volume (CTV) defined as PVTT only to a total dose of 60 Gy using 10-MV accelerator. RESULTS: A total of 19 patients were enrolled in this study. Survival rates at 1 and 2 years were 40.6% and 10.2%, respectively. The median survival time was 7.0 months. An objective response was observed in 11 of 19 cases (57.9%). Recanalization of the first portal branches was not observed; however, the protrusion of PVTT into the main portal trunk decreased in all cases. Growth of intrahepatic metastasis outside the 3D-CRT field was observed in 12 cases (63%). Deterioration of the Child-Pugh Score was observed in 5 of 6 cases with the percent volume of the total liver receiving a dose exceeding 30 Gy (V(30)) > or =40%, vs. 2 of 13 cases with a V(30) <40% (p < 0.01). CONCLUSION: This combined therapy was feasible. Our results indicate that V(30) was a predictive test for deterioration of liver function. Further investigation of treatment modalities is needed to prevent the growth of intrahepatic metastasis.

Double cancer, cholangiocellular and hepatocellular carcinomas, in the cirrhotic liver.

A 70-year-old male patient presented with cirrhotic liver caused by hepatitis C virus and complicated with hepatocellular carcinoma. The carcinoma was effectively treated by transarterial chemoembolization, but cholangiocellular carcinoma occurred in a different segment of the liver and rapidly grew and metastasized systemically. He died 13 months after the first admission. Double cancer of the liver is uncommon, but it must be considered in the differential diagnosis of cases of hepatocellular carcinoma associated with chronic hepatitis or cirrhosis. Failure to note the occurrence of cholangiocellular carcinoma is thought to be a diagnostic pitfall in the follow-up studies of patients with hepatocellular carcinoma.