External validation of the Heidenreich criteria for patient selection for unilateral or bilateral retroperitoneal lymph node dissection for post-chemotherapy residual masses of testicular cancer

Objective

To validate the Heidenreich criteria for patient selection for unilateral retroperitoneal lymph node dissection (RPLND) for residual masses after chemotherapy for nonseminomatous germ cell tumor (NSGCT).

Subjects/patients and methods

For validation, the data of 59 patients who underwent RPLND for residual masses of NSGCT were used. Of these patients, 23 (39 %) qualified for a modified RPLND, the others had an indication for a bilateral dissection. Results from histopathology after RPLND and follow-up data for relapse inside or outside the zone of the resection template were considered for validation.

Results

In the study cohort, median age at time of RPLND was 31 years. The 2-year disease-free survival was 90 and 96 % for the bilateral and the unilateral RPLND patients, respectively. Overall, 8 (14 %) relapses were observed after a median follow-up of 54 month. Of these, 6 were outside of the resection field and 2 were in-field. Of the 23 patients with indication for a modified RPLND, 1 patient relapsed in the contralateral testis and 1 inside the modified RPLND template. No relapse was observed outside the modified RPLND field and inside the untouched contralateral RPLND field. The Heidenreich criteria did therefore not misclassify a single patient.

Conclusion

The Heidenreich criteria for the selection of candidates for unilateral RPLND for residual masses after chemotherapy allow a highly reliable selection of patients. The application of the Heidenreich criteria can help to reduce comorbidity and invasiveness of RPLND.     

Patency of the supraclinoid internal carotid artery branches after flow diversion treatment. A meta-analysis

Background and purpose

Placement of flow-diverters across the ostia of major ICA branches carries a risk of arterial occlusion. We determined the rate of occlusion of the supraclinoid ICA branches and the related symptoms, following coverage with flow-diverters.

Intravoxel Incoherent Motion Diffusion-weighted Imaging in Nonalcoholic Fatty Liver Disease: A 3.0-T MR Study

Purpose: To compare pure molecular diffusion, D, perfusion-related diffusion, D*, and perfusion fraction, f, determined from diffusion-weighted (DW) magnetic resonance (MR) imaging on the basis of the intravoxel incoherent motion (IVIM) theory in patients with type 2 diabetes with and without liver steatosis. Materials and Methods: This prospective study was approved by the appropriate ethics committee, and written informed consent was obtained from all patients. Between December 2009 and September 2011, 108 patients with type 2 diabetes (51 men, 57 women; mean age, 50 years) underwent 3.0-T single-voxel point-resolved proton MR spectroscopy of the liver (segment VII) to calculate the liver fat fraction from water (4.76 ppm) and methylene (1.33 ppm) peaks, corrected for T1 and T2 decay. Steatosis was defined as a liver fat fraction of at least 5.56%. DW imaging was performed by using a single-shot echo-planar sequence with 11 b values (0, 5, 15, 25, 35, 50, 100, 200, 400, 600, 800 sec/mm(2)). Liver D, D*, and f were measured and compared in patients with and patients without steatosis (Mann-Whitney test). Results: The mean liver fat fraction was 7.8% (standard deviation, 9%; range, 0.99%-45%). Forty patients had liver steatosis. D was significantly lower in steatotic compared with nonsteatotic livers (mean, 1.03 × 10(-3) mm(2)/sec ± 0.23 [standard deviation] vs 1.24 × 10(-3) mm(2)/sec ± 0.15, respectively; P < .0001), as was D* (mean, 72.2 × 10(-3) mm(2)/sec ± 61.4 vs 110.6 × 10(-3) mm(2)/sec ± 79; P = .0025). However, f was significantly higher in steatotic compared with nonsteatotic livers (mean, 33.8% ± 9.4 vs 26.9% ± 8.8; P = .0003). Conclusion: D is significantly decreased in steatosis. The reduction in D* reflects decreased liver parenchymal perfusion in steatosis. Therefore, steatosis can affect diffusion parameters obtained with IVIM. ? RSNA, 2012.     

Lamivudine therapy of chronic hepatitis B in three groups of patients: non transplanted patients, liver recipients, and kidney recipients

OBJECTIVE: As conflicting results have been observed by some authors in liver recipients, the aim of the study was to evaluate lamivudine therapy in 3 groups of patients with chronic hepatitis B: non-transplanted patients, liver and kidney recipients.METHODS: All patients were studied for clinical symptoms, hepatic enzymes, hepatitis B virus (HBV) serology, serum HBV DNA load, and HBV polymerase genotype (mutations associated with lamivudine resistance).RESULTS: During the 48-144 week-long follow-up (mean: 75 weeks), 23 non-transplanted patients, 5 liver and 6 kidney recipients were studied. A sustained biochemical and virological response was obtained in 19 out of the 23 non-transplanted patients and in 4 of 6 kidney recipients, while the 5 liver recipients did not respond. After the development of lamivudine resistance, mutations rtM204V and rtL180M were detected in all studied patients, mutation rtM207I in one, with similar results from traditional nucleotide sequencing and a commercial line probe assay.CONCLUSION: The poor response to lamivudine in liver recipients requires further studies.     

Small poly-L-lysines improve cationic lipid-mediated gene transfer in vascular cells in vitro and in vivo

The potential of two small poly-L-lysines (sPLLs), low molecular weight sPLL (LMW-L) containing 7-30 lysine residues and L18 with 18 lysine repeats, to enhance the efficiency of liposome-mediated gene transfer (GT) with cationic lipid DOCSPER [1,3-dioleoyloxy-2-(N(5)-carbamoyl-spermine)-propane] in vascular smooth muscle cells (SMCs) was investigated. Dynamic light scattering was used for determination of particle size. Confocal microscopy was applied for colocalization studies of sPLLs and plasmid DNA inside cells. GT was performed in proliferating and quiescent primary porcine SMCs in vitro and in vivo in porcine femoral arteries. At low ionic strength, sPLLs formed small complexes with DNA (50-100 nm). At high ionic strength, large complexes (>1 microm) were observed without any significant differences in particle size between lipoplexes (DOCSPER/DNA) and lipopolyplexes (DOCSPER/sPLL/DNA). Both sPLLs were colocalized with DNA inside cells 24 h after transfection, protecting DNA against degradation. DOCSPER/sPLL/DNA formulations enhanced GT in vitro up to 5-fold, in a porcine model using local periadventitial application up to 1.5-fold. Both sPLLs significantly increased liposome-mediated GT. Poly-L-lysine L18 was superior to LMW-L since it enabled maximal GT at a 10-fold lower concentration. Thus, sPLLs may serve as enhancers for GT applications in SMCs in vitro and in vivo using local delivery.     

Pathological effects of lung radiofrequency ablation that contribute to pneumothorax,using a porcine model

Objectives: The incidence of pneumothorax is 7 times higher after lung radiofrequency ablation (RFA) than after lung biopsy. The reasons for such a difference have never been objectified. The histopathologic changes in lung tissue are well-studied and established for RF in the ablation zone. However, it has not been previously described what the nature of thermal injury might be along the shaft of the RF electrode as it traverses through normal lung tissue to reach the ablation zone. The purpose of this study was to determine the changes occurring around the RF needle along the pathway between the ablated zone and the pleura.

Material and methods: In 3 anaesthetised and ventilated swine, 6 RFA procedures (right and left lungs) were performed using a 14-gauge unipolar multi-tined retractable 3?cm radiofrequency LeVeen probe with a coaxial introducer positioned under CT fluoroscopic guidance. In compliance with literature guidelines, we implemented a gradually increasing thermo-ablation protocol using a RF generator. Helical CT images were acquired pre- and post-RFA procedure to detect and evaluate pneumothorax. Four percutaneous 19-gauge lung biopsies were also performed on the fourth swine under CT guidance. Swine were sacrificed for lung ex vivo examinations, scanning electron microscopy (SEM) and pathological analysis.

Results: Three severe (over 50?ml) pneumothorax were detected after RFA. In each one of them, pathological examination revealed a fistulous tract between ablation zone and pleura. No fistulous tract was observed after biopsies.

In the 3 cases of severe pneumothorax, the tract was wide open and clearly visible on post procedure CT images and SEM examinations. The RFA tract differed from the needle biopsy tract. The histological changes that are usually found in the ablated zone were observed in the RFA tract’s wall and were related to thermal lesions. These modifications caused the creation of a coagulated pulmonary parenchyma rim between the thermo-ablation zone and the pleural space. The structural properties of the damage can explain why the RFA tract is remains patent after needle withdrawal.

Conclusion: Our study demonstrates for the first time that the changes around the RF needle are the same as in the ablated zone. The damage could create fistulous tracts along the needle path between thermo-ablation zone and pleural space. These fistulas could certainly be responsible for severe pneumothorax that occurs in many patients treated with lung RFA.     

Gastrointestinal bleeding and obstructive jaundice:Think of hepatic artery aneurysm

Hemobilia is an uncommon and potential life-threatening condition mainly due to hepato-biliary tree traumatic or iatrogenic injuries.Spontaneously ruptured aneurysm of the hepatic artery is seldom described.We report the case of an 89-year-old woman presenting with abdominal pain,jaundice and gastrointestinal bleeding,whose ultrasound and computed tomography revealed a non-traumatic,spontaneous aneurysm of the right hepatic artery.The oeso-gastro-duodenoscopy and colonoscopy did not reveal any bleeding at the ampulla of Vater,nor anywhere else.Selective angiography confirmed the diagnosis of hepatic artery aneurysm and revealed a full hepatic artery originating from the superior mesenteric artery.The patient was successfully treated by selective embolization of microcoils.We discuss the etiologies of hemobilia and its treatment with selective embolization,which remains favored over surgical treatment.Although aneurysm of the hepatic artery is rare,especially without trauma,a high index of suspicion is needed in order to ensure appropriate treatment.