Radiological differences between chronic thromboembolic pulmonary disease (CTEPD) and chronic thromboembolic pulmonary hypertension (CTEPH).

OBJECTIVES: The aim of this study was to describe the radiological features of chronic thromboembolic pulmonary disease (CTEPD), not yet systematically described in the literature. Furthermore, we compared vascular scores between CTEPD and chronic thromboembolic pulmonary hypertension (CTEPH) patients, trying to explain why pulmonary hypertension does not develop at rest in CTEPD patients. METHODS: Eighty-five patients (40 CTEPD, 45 CTEPH) referred to our centre for pulmonary endarterectomy underwent dual-energy computed tomography pulmonary angiography (DE-CTPA) with iodine perfusion maps; other 6 CTEPD patients underwent single-source CTPA. CT scans were reviewed independently by an experienced cardiothoracic radiologist and a radiology resident to evaluate scores of vascular obstruction, hypoperfusion and mosaic attenuation, signs of pulmonary hypertension and other CT features typical of CTEPH. RESULTS: Vascular obstruction burden was similar in the two groups (p = 0.073), but CTEPD patients have a smaller extension of perfusion defects in the iodine map (p = 0.009) and a smaller number of these patients had mosaic attenuation (p < 0.001) than CTEPH patients, suggesting the absence of microvascular disease. Furthermore, as expected, the two groups were significantly different considering the indirect signs of pulmonary hypertension (p < 0.001). CONCLUSIONS: CTEPD and CTEPH patients have significantly different radiological characteristics, in terms of signs of pulmonary hypertension, mosaic attenuation and iodine map perfusion extension. Importantly, our results suggest that the absence of peripheral microvascular disease, even in presence of an important thrombotic burden, might be the reason for the absence of pulmonary hypertension in CTEPD. KEY POINTS: • CTEPD and CTEPH patients have significantly different radiological characteristics. • The absence of peripheral microvascular disease might be the reason for the absence of pulmonary hypertension in CTEPD.

Endovascular Exclusion of Aortobronchial Fistula and Distal Anastomotic Aneurysm after Extra-Anatomic Bypass for Aortic Coarctation.

The treatment of choice for aortic coarctation in adults remains open surgical repair. Aortobronchial fistula is a rare but potentially fatal late sequela of surgical correction of isthmic aortic coarctation via the interposition of a graft. The endovascular treatment of aortobronchial fistula is still under discussion because of its high risk for infection, especially if the patient has a history of cardiovascular prosthetic implantation. Patients need close monitoring, most notably those with secondary aortobronchial fistula. We discuss the case of a 65-year-old man who presented with the combined conditions, and we briefly review the relevant medical literature.

Patient dose during carotid artery stenting with embolic-protection devices: evaluation with radiochromic films and related diagnostic reference levels according to factors influencing the procedure.

PURPOSE: To measure the maximum entrance skin dose (MESD) on patients undergoing carotid artery stenting (CAS) using embolic-protection devices, to analyze the dependence of dose and exposure parameters on anatomical, clinical, and technical factors affecting the procedure complexity, to obtain some local diagnostic reference levels (DRLs), and to evaluate whether overcoming DRLs is related to procedure complexity. MATERIALS AND METHODS: MESD were evaluated with radiochromic films in 31 patients (mean age 72 ± 7 years). Five of 33 (15 %) procedures used proximal EPD, and 28 of 33 (85 %) procedures used distal EPD. Local DRLs were derived from the recorded exposure parameters in 93 patients (65 men and 28 women, mean age 73 ± 9 years) undergoing 96 CAS with proximal (33 %) or distal (67 %) EPD. Four bilateral lesions were included. RESULTS: MESD values (mean 0.96 ± 0.42 Gy) were <2 Gy without relevant dependence on procedure complexity. Local DRL values for kerma area product (KAP), fluoroscopy time (FT), and number of frames (NFR) were 269 Gy cm(2), 28 minutes, and 251, respectively. Only simultaneous bilateral treatment was associated with KAP (odds ratio [OR] 10.14, 95 % confidence interval [CI] 1-102.7, p < 0.05) and NFR overexposures (OR 10.8, 95 % CI 1.1-109.5, p < 0.05). Type I aortic arch decreased the risk of FT overexposure (OR 0.4, 95 % CI 0.1-0.9, p = 0.042), and stenosis ≥ 90 % increased the risk of NFR overexposure (OR 2.8, 95 % CI 1.1-7.4, p = 0.040). At multivariable analysis, stenosis ≥ 90 % (OR 2.8, 95 % CI 1.1-7.4, p = 0.040) and bilateral treatment (OR 10.8, 95 % CI 1.1-109.5, p = 0.027) were associated with overexposure for two or more parameters. CONCLUSION: Skin doses are not problematic in CAS with EPD because these procedures rarely lead to doses >2 Gy.

Concurrent intra-arterial carboplatin administration and radiation therapy for the treatment of advanced head and neck squamous cell carcinoma: short term results.

BACKGROUND: The aim of the present study was to evaluate the survival, efficacy and safety of a modified RADPLAT-like protocol using carboplatin instead of cisplatin. METHODS: Fifty-six patients with primary head and neck squamous cell carcinoma received 4 cycles of intra-arterial carboplatin (350 mg/m2 per cycle every 2 weeks), with concurrent three-dimensional conformal radiation therapy. RESULTS: Two major and 4 minor complications were observed. Forty-five of the 56 patients (80%) completed the protocol, while 11 (20%) patients had to discontinue the intra-arterial infusions due to the occurrence of severe haematological toxicity, but were able to complete radiotherapy. Forty-four (98%) of the 45 patients who completed the protocol and 10 (91%) of the 11 who did not, were free of disease at the end of the treatment, for a comprehensive 96% of CR overall. After a median 23.55 months (range: 2 to 58 months) of follow-up, 40 patients (71%) are alive and disease-free, 1 (2%) is alive but affected by disease and 15 (27%) have died of the disease or other causes. CONCLUSION: Intra-arterial carboplatin administration with concurrent three-dimensional conformal radiation therapy seems to be a promising alternative to RADPLAT in the treatment of advanced head and neck tumours. Haematological and non-haematological toxicities are virtually similar, but carboplatin has the advantage in that it is not nephrotoxic and can be used at very high doses without any significant increase in the extent of side effects.

Transhepatic arterial chemoembolization with oxaliplatin-eluting microspheres (OEM-TACE) for unresectable hepatic tumors.

BACKGROUND: While conventional transhepatic arterial chemoembolization (TACE) is accepted worldwide as an effective treatment for patients with unresectable hepatocellular carcinoma (HCC), its use in other hepatic tumors is not supported by randomized studies. Preliminary results have shown that new drug-eluting microspheres (DEM) seem to optimize TACE procedures. The aim of this study was to evaluate the capability of HepaSphere to load oxaliplatin and their pharmacokinetic outcome. The feasibility and safety of treatment with oxaliplatin-eluting microspheres (OEM-TACE) was also evaluated in patients with unresectable liver metastasis of colorectal cancer and unresectable intrahepatic cholangiocarcinoma. PATIENTS AND METHODS: An inductively coupled plasma mass spectrometer (ICP-MS) was used to quantify the oxaliplatin bound to microspheres and the oxaliplatin in liver biopsies. Fifteen patients (8 with colorectal carcinoma liver metastases, 7 with intrahepatic cholangiocarcinoma) were treated with 27 sessions of OEM-TACE. RESULTS: The data suggested that the microspheres can bind oxaliplatin entirely. The pharmacokinetic parameters were significantly different between the OEM-TACE patients and a control group of patients treated with oxaliplatin chemotherapy. The mean oxaliplatin concentration within the tumor was twenty-times higher than the extratumoral liver concentration in the OEM-TACE patients. According to response evaluating criteria in solid tumors (RECIST), stable disease was observed in 8 out of the 15 patients (53.3%), a partial response in 2 (13.3%) and intrahepatic or extrahepatic tumor progression in 5 out of the 15 patients (33.3%). No major adverse event (AE G3/4) occurred. CONCLUSION: TACE with oxaliplatin-loaded microspheres is a safe and feasible treatment without major adverse events and with a favorable pharmacokinetic profile.

Radiochromic films for improved evaluation of patient dose in liver interventions.

PURPOSE: To investigate a method for evaluation of the maximum skin dose (MSD) of radiation in patients undergoing interventional radiology procedures in the liver. MATERIALS AND METHODS: Transarterial chemoembolization, transarterial embolization, portal vein embolization, and biliary interventions were the procedures considered in this study. Ninety procedures in 70 patients were studied. The complexity of the biliary interventions was taken into account during the analysis. The MSD was measured with use of GAF chromic XR type R films, whereas the dose-area product (DAP) was measured by a transmission chamber. RESULTS: The MSD was measured in a group of 19 patients. The coefficient of the interpolation line between the skin dose and the DAP (0.0051 cm(-2)) was determined. An approximated value of MSD from the DAP for the remaining 71 procedures was estimated by means of an interpolation line. The mean MSD in the endovascular procedures was 4.4 Gy; for the three different levels of complexity of the biliary procedures, the mean MSDs were 0.4, 1.2, and 3 Gy, respectively. CONCLUSIONS: Radiochromic films are an easy-to-use and efficient method for measuring skin entrance radiation dose and have the advantage of providing information on the MSD as well as the distribution of radiation to the skin. In light of these results, the authors suggest recording the dose for biliary and endovascular procedures as indicated by the International Commission on Radiological Protection and the United States Food and Drug Administration.

Characterization of focal liver lesions with a new ultrasound contrast agent using continuous low acoustic power imaging: comparison with contrast enhanced spiral CT.

PURPOSE: To evaluate the concordance of the enhancement patterns of a new ultrasound contrast agent (SonoVue) with those obtained with dual-phase contrast-enhanced spiral CT (CE-CT) in the characterization of focal liver lesions (FLLs). MATERIALS AND METHODS: Sixty-two patients with focal liver lesions discovered at ultrasound and also studied with CECT underwent contrast-enhanced ultrasound using continuous low acoustic power imaging after receiving a 2.4 ml bolus of the new US contrast agent SonoVue, consisting of a dispersion of sulphur hexafluoride microbubbles. The examinations were made using ATL HDI-5000, Acuson SEQUOIA and Aloka 5500 Prosound ultrasound systems with 5.2 MHz curved-array probes. The concordance between US and CE-CT images was evaluated on site by two radiologists blinded to CT RESULTS: The FLLs were assessed in the arterial (20 s after CM injection), portal (after 45-60 s) and late (after 120 s) phases for: 1) presence/absence of enhancement 2) distribution of enhancement (homogenous or target distribution, centripetal or centrifugal flow, and other), 3) qualitative enhancement pattern (hyperechoic, hypoechoic, or isoechoic) versus normal liver parenchyma. RESULTS: The concordance between SonoVue-enhanced US and CE-CT was 85%. Moreover during portal venous phase with CEUS it was possible to differentiate between malignancy or benignity of 91% of lesions. CONCLUSIONS: The preliminary data obtained in this study suggest that continuous low acoustic power imaging and contrast-enhanced US show similar results to CT in contrast distribution and contrast enhancement patterns.