Resectability and Ablatability Criteria for the Treatment of Liver Only Colorectal Metastases: Multidisciplinary Consensus Document from the COLLISION Trial Group.

The guidelines for metastatic colorectal cancer crudely state that the best local treatment should be selected from a 'toolbox' of techniques according to patient- and treatment-related factors. We created an interdisciplinary, consensus-based algorithm with specific resectability and ablatability criteria for the treatment of colorectal liver metastases (CRLM). To pursue consensus, members of the multidisciplinary COLLISION and COLDFIRE trial expert panel employed the RAND appropriateness method (RAM). Statements regarding patient, disease, tumor and treatment characteristics were categorized as appropriate, equipoise or inappropriate. Patients with ECOG≤2, ASA≤3 and Charlson comorbidity index ≤8 should be considered fit for curative-intent local therapy. When easily resectable and/or ablatable (stage IVa), (neo)adjuvant systemic therapy is not indicated. When requiring major hepatectomy (stage IVb), neo-adjuvant systemic therapy is appropriate for early metachronous disease and to reduce procedural risk. To downstage patients (stage IVc), downsizing induction systemic therapy and/or future remnant augmentation is advised. Disease can only be deemed permanently unsuitable for local therapy if downstaging failed (stage IVd). Liver resection remains the gold standard. Thermal ablation is reserved for unresectable CRLM, deep-seated resectable CRLM and can be considered when patients are in poor health. Irreversible electroporation and stereotactic body radiotherapy can be considered for unresectable perihilar and perivascular CRLM 0-5cm. This consensus document provides per-patient and per-tumor resectability and ablatability criteria for the treatment of CRLM. These criteria are intended to aid tumor board discussions, improve consistency when designing prospective trials and advance intersociety communications. Areas where consensus is lacking warrant future comparative studies.

[A boy with a spontaneous rupture of the spleen; a complication of infectious mononucleosis]. / Een jongen met een spontane miltruptuur.

BACKGROUND: Spontaneous rupture of the spleen occurs in 0.1-0.2% of patients with infectious mononucleosis and is associated with a high mortality (9-13%). Rupture is not normally preceded by a trauma. CASE DESCRIPTION: A previously healthy 17- year-old boy presented at the Emergency Department with acute onset of pain in his left upper abdomen and left shoulder. Initially he showed no signs of shock, but he did have signs of an acute abdomen. In addition, spots of pus were seen on both pharyngeal arches. Urgent ultrasound showed free fluid in his abdomen, and CT scan revealed active bleeding from the spleen. The patient underwent embolisation of the splenic artery. Serological investigations were positive for a recent infection with the Epstein-Barr virus. CONCLUSION: In young patients with signs of acute abdomen and pharyngitis, in the absence of prior trauma, spontaneous rupture of the spleen should be considered. The severity of a rupture of the spleen may initially be underestimated as haemodynamic instability and signs of shock occur only at a late stage.

Short-term Results of the RAPID Randomized Trial of the Legflow Paclitaxel-Eluting Balloon With Supera Stenting vs Supera Stenting Alone for the Treatment of Intermediate and Long Superficial Femoral Artery Lesions.

PURPOSE: To report a randomized trial comparing the Legflow paclitaxel-eluting balloon (PEB) + Supera stenting to Supera stenting alone in patients with intermediate to long superficial femoral artery (SFA) lesions. METHODS: The multicenter RAPID trial ( controlled-trials.com ; identifier ISRCTN47846578) randomized (1:1) 160 patients (mean age 67 years; 102 men) with Rutherford category 2-6 ischemia to treatment with Legflow PEB + Supera stent or Supera stent alone in intermediate to long SFA lesions (mean lesion length 15.8±7.4 vs 15.8±7.6 cm, respectively). The efficacy outcome was primary patency, defined as freedom from restenosis on duplex ultrasound or angiography. RESULTS: Baseline characteristics including the percentage of occlusions were similar between groups. In the intention-to-treat analysis, the estimated primary patency at 1 year was 68.3% (95% CI 56.7% to 79.9%) in the PEB + Supera group vs 62.0% (95% CI 49.1% to 74.9%) in the Supera group (p=0.900). Per-protocol analysis showed a 12-month primary patency estimate of 74.7% (95% CI 63.1% to 86.3%) in the PEB + Supera group vs 62.0% (95% CI 49.1% to 74.9%) in the control group (p=0.273). Secondary patency estimates at 12 months (per-protocol analysis) were 89.0% (95% CI 80.6% to 97.4%) vs 98.0% (95% CI 94.1% to 100%; p=0.484); the estimates for freedom from clinically driven target lesion revascularization (CD-TLR) were 83.0% (95% CI 72.8% to 93.2%) and 77.8% (95% CI 66.6% to 89.0%; p=0.277), respectively. CONCLUSION: The short-term results from the multicenter RAPID randomized controlled trial indicate that the Legflow PEB is safe and feasible for the treatment of intermediate to long SFA lesions. In this trial, at least 70% of the patients suffered an occlusion. The PEB group had higher rates of primary patency and freedom from CD-TLR, although there were no statistically significant differences vs controls.

Transpopliteal stenting of femoral occlusions in patients with critical limb ischemia using a 4-French system.

PURPOSE: In many patients with critical limb ischemia (CLI), transfemoral endovascular recanalization is the preferred treatment. Transpopliteal treatment may be used in patients with inaccessible groins. This retrospective study regards transpopliteal stenting of superficial femoral artery (SFA) occlusions using a 4F system. MATERIALS AND METHODS: Eleven patients (4 male and 7 female [mean age 77 years]) underwent 12 attempts of transpopliteal recanalization of long SFA occlusions (Trans-Atlantic InterSociety Consensus B through D). All patients had CLI (Rutherford 4 to 6) and were nonoperable due to poor general condition. Indications for transpopliteal access were proximal/flush SFA occlusions (n = 5), failure of antegrade recanalization (n = 4), infected femoral-femoral crossover bypass (n = 2), and occlusion of both the native SFA and the femoral-popliteal bypass (n = 1). The popliteal artery was punctured under ultrasound guidance. Occlusions were recanalized subintimally, and 4F compatible stents were implanted. RESULTS: Technical success rate (<30 % residual stenosis) was achieved in 83 % of cases. In two patients, stent dislocation occurred while the sheath was removed. One arteriovenous fistula was successfully treated with additional stenting. During 6-month follow-up, there were no major amputations, and three patients died from nonrelated causes. Fifty percent of patients alive after 6 months improved to Rutherford score ≤3. The duplex restenosis (>50 %) rate at 6 months was 50 %. CONCLUSION: Transpopliteal primary stenting of complex SFA lesions in CLI for a temporary bypass is now technically feasible using a 4F system. Technical results are promising. Clinical results after 6 months are acceptable when taking into consideration that this approach may be the last option for limb salvage.