The high mortality rate for hepatocellular carcinoma (HCC) relative to its prevalence underscores the need for curative-intent therapies. Multidisciplinary treatment decisions are required to craft optimal treatment strategies considering tumor size, location and underlying liver cirrhosis. Surgical resection of anatomically limited tumors with adequate hepatic reserve provides long-term survival in more than half of patients and remains a standard first-line therapy. Eligibility for resection among newly diagnosed patients is low and recurrences in the remaining cirrhotic liver are common. Transplantation offers a higher chance of cure. Long wait times for the limited door pool require neoadjuvant loco-regional therapies to maintain transplant eligibility. Image-guided therapies such as ablation and embolization have an established role as primary or neoadjuvant preparing patients for curative treatment. Percutaneous ablation in appropriately selected patients offers long-term survival similar to resection. New and evolving techniques such as stereotactic body radiotherapy (SBRT), radiation segmentectomy and lobectomy, and combination therapies employing both trans-arterial and ablative approaches show promise for curative-intent treatment but require further prospective data before they can be integrated into treatment algorithms. For palliativeintent therapy, conventional trans-arterial chemoembolization with lipiodol-based emulsions remains the only technique supported by clinical trials. Newer platforms such as drug-eluting embolics failed to improve survival over bland embolization in randomized trials and showed increased hepatobiliary toxicity. Transarterial radioembolization offers similar overall survival (OS) to transarterial chemoembolization (TACE) and non-inferiority to sorafenib in meta-analyses. The more favorable clinical toxicity profile makes it an appealing technique for patients willing to accept the longer time to response.
Abstract A 68-year-old man with hereditary hypercoagulability was referred to nuclear medicine for elevated aminotransferases after a recent living-donor liver transplant. A hepatic infarction was suspected. A 99m Tc-mebrofenin SPECT/CT was performed and showed decreased radiotracer uptake in a wedge-shaped distribution in the anterior liver suggestive of a hepatic infarction. Subsequently, an enhanced MRI corroborated the diagnosis. Oral anticoagulation therapy was then initiated, and aminotransferases soon normalized.
Lymphatic plastic bronchitis (LPB) is a rare condition with expectoration of bronchial casts that can result in airway obstruction. The cause of LPB is shown to be abnormal lymphatic flow into the bronchial tree. The objective of the study is to summarize our experience in the diagnosis and treatment of LPB. A prospectively collected, retrospective reviewed database identified 57 patients who were referred for the management of LPB. Initially dynamic contrast-enhanced MR lymphangiography (DCMRL) was performed if possible to confirm the diagnosis followed by embolization of the thoracic duct (TD) and/or TD branches. Baseline demographics, comorbidities, DCMRL findings, technical success, immediate and long-term clinical outcomes, and follow-up length were collected. Baseline demographics were summarized in Table 17.1. 42 (73%) patients were obese, 10 (18%) overweight, and 4 (9%) normal BMI. 46/57 patients underwent DCMRL and 11/57 could not tolerate or were contraindicated to DCMRL. In 44/46 patients DCMRL showed abnormal pulmonary lymphatic flow and in 2 patients DCMRL was not diagnostic. TD cannulation was attempted with a technical success rate of 97.8% (56/57). In all 56 patients, TD lymphangiography demonstrated abnormal pulmonary lymphatic flow. TD embolization (TDE) was performed in all 56 patients. Immediate complete clinical success was 98% (55/56). In 1 patient the clinical success was partial, due to concurrent communication between liver lymphatics and bronchial tree and the patient refused repeat procedure. 53 patients were available for long-term follow-up (mean follow-up length: 1265 days; range 31–3364 days). LPB recurred in 8 patients after average 607 days (range 16–3364 days). 5 underwent repeat lymphatic imaging and/or intervention with complete resolution in 4 patients. Median number of TDE procedure was 1 (range 1-4). The overall clinical success rate of patients with long-term follow up was 92.4% (49/53). The incidence of obesity is high in LPB patients suggesting obesity may be a risk factor of LPB. DCMRL can identify abnormal lymphatic pulmonary perfusion to confirm the diagnosis. TDE is an effective treatment in the majority of patients both immediately and at long-term follow up with low incidence of recurrence.
An elderly patient was admitted for a coronary artery bypass graft. The postoperative course was complicated by decompensated atrial fibrillation requiring repeat endotracheal intubation.
On examination subcutaneous emphysema was noted, which progressed to involve the upper arms, cervical region and face.
Chest X-ray and CT scan demonstrated subcutaneous emphysema and pneumomediastinum (figures 1 and 2). Fibre optic bronchoscopy revealed a normal tracheobronchial tree, without obvious orifices in the tracheal wall. A CT scan of the thorax revealed a tracheal diverticulum on the right posterolateral aspect of the …
Cystic Fibrosis (CF) lung damage begins early in life. Lung function decline is associated with pulmonary infections, neutrophil infiltration and inflammation. In CF, neutrophils have an altered phenotype. In this pilot study, we aimed to determine if signals of dysfunctional neutrophil responses were evident early in life and whether these signals may be associated with lung damage in later childhood. We examined the pulmonary protein profiles of 14 clinical stable infants and pre-school children with CF employing the aptamer-based affinity platform, SOMAscan®. High resolution computed tomography (HRCT) was performed on all children after age 6 years and Brody score calculated. A Spearman's rank order correlation analysis and Benjamini-Hochberg adjustment was used to correlate protein concentrations in early life to Brody scores in later childhood. Early life concentrations of azurocidin and myeloperoxidase, were positively correlated with Brody score after age 6 ( p = 0.0041 and p = 0.0182, respectively). Four other neutrophil associated proteins; Complement C3 ( p = 0.0026), X-ray repair CCP 6 ( p = 0.0059), C3a anaphylatoxin des Arginine ( p = 0.0129) and cytokine receptor common subunit gamma ( p = 0.0214) were all negatively correlated with Brody scores. Interestingly, patients with more severe lung damage after age 6 had significantly lower levels of IL-22 in early years of life ( p = 0.0243). IL-22 has scarcely been reported to have implications in CF. Identification of early biomarkers that may predict more severe disease progression is particularly important for the future development of early therapeutic interventions in CF disease. We recommend further corroboration of these findings in prospective validation studies.
Pseudocirrhosis is defined by radiologic changes of the liver parenchyma secondary to metastatic disease and/or cancer treatments, and portends a high rate of morbidity and mortality from sequelae of portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment for portal hypertension; however, TIPS is relatively contraindicated in the setting of hepatic metastases. The study aims to determine the technical efficacy and clinical outcomes of patients undergoing TIPS for symptomatic pseudocirrhosis.Retrospective analysis of patients with hepatic malignancy who underwent TIPS between 2008 and 2020 at a single tertiary care center. Patients with imaging findings of pseudocirrhosis and without history of primary liver malignancy or confounding causes of cirrhosis were included. West Haven scores assessing hepatic encephalopathy were obtained from chart review. Technical success was defined as successful TIPS creation with reduction in the portosystemic gradient (PSG). Clinical success was defined as resolution of variceal bleeding and/or ascites.Nine patients (4 female/5 male), average (± SD) age 61.2±9.5 years with metastatic pseudocirrhosis were included for analysis. Primary malignancy was colorectal adenocarcinoma (n=5), neuroendocrine tumor (n=3), and malignant endothelial hemangioendothelioma (n=1). Average Model for End Stage Liver Disease (MELD-Na) score was 15.7±3.7. Technical success was 8/9 (89%) with average PSG reduced from 23.5±11.0 to 6.5±2.8 mmHg (P=0.001). Clinical success was 6/9 (67%). Two patients required TIPS revision after initial clinical success. Mild-moderate HE occurred in 6/9 patients post TIPS (67%), with a highest West Haven score of 2. Time from TIPS to death for acute variceal bleeding and ascites was 4.9±4.2 and 12±16.5 months, respectively. Cause of death was disease progression (n=5), variceal bleeding (n=1), or unavailable (n=2).TIPS in the setting of malignant pseudocirrhosis can be created safely with similar clinical outcomes to TIPS performed for benign disease. Rates of low-grade hepatic encephalopathy may be higher amongst patients undergoing TIPS for pseudocirrhosis.
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