Management of malignant biliary obstruction: Technical and clinical results using an expanded polytetrafluoroethylene fluorinated ethylene propylene (ePTFE/FEP)-covered metallic stent after 6-year experience

To evaluate the efficacy and safety of an expanded polytetrafluoroethylene-fluorinated ethylene-propylene (ePTFE/FEP)-covered metallic stent in the management of malignant biliary obstruction. Eighty consecutive patients with malignant common bile duct strictures were treated by placement of 83 covered metallic stents. The stent-graft consists of an inner ePTFE/FEP lining and an outer supporting structure of nitinol wire. Clinical evaluation, assessment of serum bilirubin and liver enzyme levels were analyzed before biliary drainage, before stent-graft placement and during the follow-up period at 1, 3, 6, 9 and 12 months. Technical success was obtained in all cases. After a mean follow-up of 6.9±4.63 months, the 30-day mortality rate was 14.2%. Survival rates were 40% and 20.2% at 6 and 12 months, respectively. Stent-graft patency rates were 95.5%, 92.6% and 85.7% at 3, 6 and 12 months, respectively. Complications occurred in five patients (6.4%); among these, acute cholecystitis was observed in three patients (3.8%). A stent-graft occlusion rate of 9% was observed. The percentage of patients undergoing lifetime palliation (91%) and the midterm patency rate suggest that placement of this ePTFE/FEP-covered stent-graft is safe and highly effective in achieving biliary drainage in patients with malignant strictures of the common bile duct.     

Selective endovascular treatment of a traumatic basilar aneurysm after endoscopic third ventriculostomy

A 4-year-old girl suffered intraventricular and subarachnoid hemorrhage during endoscopic third ventriculostomy. Cerebral angiography revealed a traumatic basilar aneurysm secondary to basilar artery injury. The aneurysm was treated with selective endovascular embolization using Guglielmi detachable coils. We review some therapeutic features of traumatic basilar aneurysms after endoscopic third ventriculostomy and describe the feasibility of endovascular selective therapy to manage these lesions successfully.     

The influence of the lower patellar pole in the pathogenesis of chronic patellar tendinopathy

Resection of the lower patellar pole provides good results in the treatment of jumper’s knee. Therefore we hypothesized that the length of the lower patellar pole is increased in patients with chronic patellar tendinopathy. Cohort study, level of evidence 2. Between 2000 and 2005, 25 patients with chronic patellar tendinopathy underwent conservative and surgical treatment in our clinic. All of them had preoperative MRI were three independent examiners measured the Caton Index, the length and the ratio of the articular and non-articular patellar surface, tendon length and thickness and the thickness and length of the hypodens lesions in the patellar tendon. The measurements were compared with 50 MRI of a control group with no clinical patellofemoral disorders or patellar tendinopathy. Significant changes in tendon thickness (9.42 ± 2.87 vs. 4.88 ± 1.13; P < 0.0001), a longer non-articular surface of the patella (10.62 ± 2.86 vs. 7.098 ± 2.53; P < 0.0001) and significant higher ratio between the articular and the non-articular patellar surface (0.32 vs. 0.24; P < 0.0001) were found in the jumper’s knee group. No significant changes were seen in the length of the articular surface or the Caton Index. The development of chronic patellar tendinopathy in athletes might be associated with a longer lower patellar pole as patients with jumper’s knee showed a longer non-articular patellar surface compared with the control group.     

Ossifying chondroid lipoma

Chondroid lipoma is a rare variant of lipoma that pathologically can mimic liposarcoma or possibly other sarcomas. Variants of lipoma, including chondroid lipoma, may demonstrate radiological evidence of fat within the tumor, but often display heterogeneous features on imaging studies, making a clinical diagnosis difficult. A large collective experience with the imaging characteristics of chondroid lipoma is lacking due to the rarity of this tumor. We present a case of chondroid lipoma of the upper thigh in a 37-year-old woman who had regions of metaplastic bone formation within the tumor. Radiologically, the tumor presented as a large soft tissue mass with calcification and ossification. Although metaplastic bone formation in conventional lipoma is well described, it has been rarely reported to occur in chondroid lipoma and has not been pathologically documented or illustrated. The imaging findings and histopathology of this unusual tumor are presented, along with a review of the literature.     

Cardiovascular risk,obesity, and myocardial blood flow in postmenopausal women

Background. This study was designed to determine whether overweight or obese status is independently associated with myocardial flow reserve (MFR), an established predictor of cardiovascular mortality, in a group of postmenopausal women with no previous cardiovascular disease. Postmenopausal women are the largest group of overweight and physically inactive individuals in the United States. Increased body mass index (BMI) is consistently associated with increased cardiovascular mortality in this population. Whether this is because of obesity itself or the accompanying increase in cardiovascular risk factors (CRFs) remains controversial. Methods. We examined the relationship of myocardial blood flow (MBF), coronary vascular resistance, and MFR to BMI in 60 postmenopausal women with no coronary heart disease. Subjects underwent dynamic N-13 ammonia positron emission tomography for the measurement of MBF and MFR. Baseline demographics, CRF, and hemodynamic parameters were recorded for each subject. Datasets were divided into 3 groups according to BMI: normal (18 to 24), overweight (25 to 29), and obese (≥30). Results. The overweight and obese groups showed significantly higher resting MBF and lower MFR than the normal-weight group (both P<.001), even after adjusting for CRF. A further analysis of subjects without any CRF (n=35) showed that the MFR remained significantly lower in the obese compared with normal-weight subjects (P=.05). Levels of known markers of vascular inflammation (high-sensitivity C-reactive protein and homocysteine) and high-density lipoprotein cholesterol levels correlated with declining MFR. Conclusions. These findings provide a mechanistic link between obesity and coronary heart disease in this population. This study was funded by a Veterans Health Administration MERIT Review Award. C.S.D. is on the Speaker’s Bureau at Pfizer, Inc., and has received grant support from Pfizer, Inc., Eli Lilly & Co., and the Veterans Health Administration.     

Comparison of 64-slice cardiac computed tomography with myocardial perfusion scintigraphy for assessment of global and regional myocardial function and infarction in patients with low to intermediate likelihood of coronary artery disease

Background. Cardiac computed tomography (CCT) has the potential to assess both coronary anatomy and ventricular function in a single study. We examined the agreement between CCT and myocardial perfusion scintigraphy (MPS) for the assessment of global and regional ventricular function. Methods and Results. Research CCT was performed in 52 patients with a low to intermediate likelihood of coronary artery disease referred for MPS. Left ventricular enddiastolic volume, left ventricular end-systolic volume, left ventricular ejection fraction (LVEF), and myocardial wall motion and thickening were compared between techniques. In addition, myocardial contrast attenuation on CCT was compared with radiotracer uptake on MPS. LVEF values agreed well (mean difference, 4.1%; SD, 15.13%), but CCT left ventricular end-diastolic volume was greater compared with MPS (mean difference, 46.0 mL; SD, 33.34 mL) (P<.001). There was moderate agreement for segmental myocardial motion and thickening, with κ values of 0.57 (95% confidence interval, 0.51–0.63) and 0.47 (95% confidence interval, 0.41–0.53), respectively. Seventeen patients had hypoattenuation in at least 1 myocardial segment on CCT. Three of four patients with concomitant abnormalities of wall motion and thickening on CCT had infarction in the same territory on MPS. Conclusions. There was good agreement for LVEF between CCT and MPS but myocardial volumes differed, and these modalities cannot be used interchangeably. Mild abnormalities of regional function are detected more commonly by CCT than by MPS. Myocardial hypoattenuation on CCT is highly specific for myocardial infarction when associated with reduction of systolic wall thickening and regional wall motion abnormality. Dr Nicol received a grant from the Defence Postgraduate Medical Deanery.     

Clinical and structural results of partial supraspinatus tears treated by subacromial decompression without repair

Patients with primary impingement and articular sided partial tears of the supraspinatus are often treated by subacromial decompression without repair, if the extent of the tear is estimated to be below 50% of tendon thickness. It has been questioned whether repair of these cuff lesions is necessary, because these tears could progress to full thickness tears with deteriorating clinical results. Our hypothesis was that subacromial decompression without repair of the supraspinatus tendon leads to significant clinical improvement for patients with grade I and II articular sided tears without progression to a full thickness tear on a regular basis. 46 consecutive patients (av. Age 59.2 years, range 33–76.6 years) were retrospectively reviewed after an average follow up of 50.3 months (36–86 months). 26 patients (43.5%) had a grade I tear according to Ellman, which was left alone, 20 patients suffered from a grade II tear, which was debrided. Clinical outcome was assessed with the ASES Score and ultrasound evaluation was performed on all patients to detect possible progression to a full thickness tear. The average ASES Score significantly improved from 37.4 to 86.6 points (p < 0.0001). The mean postoperative Constant Score was 87.6 points. Only three patients (6.5%) progressed to a full thickness tear detectable on ultrasound examination. Only one of these patients had a poor result with an ASES Score of 35 points, the other two were very satisfied and had an ASES score above 90 points. 8 patients showed no more signs of partial tearing on ultrasound and these patients had an average ASES Score of 93.1 points. Overall clinical outcome was rated excellent in 35 cases (76.1%), good in 5 (10.9%), average in 2 (4.3%) and poor in 4 (8.7%). Our results indicate that good and excellent results can be achieved mid- to long term by acromioplasty without repair of the rotator cuff in articular sided partial tears grade I and II. These results reach almost 95% of the value of a healthy shoulder. A better result on ultrasound examination was associated with a superior clinical outcome, while progression to a full thickness tear was rare.     

Endoscopic calcaneoplasty combined with Achilles tendon repair

Endoscopic calcaneoplasty is a minimally invasive technique for resection of inflamed retrocalcaneal bursa as well as the posterosuperior part of the calcaneus. A relative contra-indication for this technique is a tear of the Achilles tendon. In this report, we describe the treatment of a patient with Haglund’s deformity associated with a tear of the Achilles tendon. Both the lesions are treated endoscopically. The technique is described and the pitfalls are discussed.     

Selective hepatic arterial infusion of In-111-DTPA-Phe<Superscript>1</Superscript>-octreotide in neuroendocrine liver metastases

Purpose  The aim of this study is to evaluate the effectiveness of ¹¹¹In-DTPA-Phe¹-octreotide infusions after selective catheterization of the hepatic artery in inoperable metastasised liver, sst₂ receptor-positive neuroendocrine tumours due to the effect of ¹¹¹In Auger electron emission, minimising in parallel the toxicity of non-target tissue. Methods  The average dose per session administered monthly to each patient (17 cases in total) was 6.3 ± 2.3 GBq. Repetitions did not exceed 12-fold, except in one case (15 sessions). Response assessment was classified according to the Response Evaluating Criteria in Solid Tumours. CT/MRI scans were performed as baseline before, during and after the end of treatment, and monthly ultrasound images for follow-up measurements. Toxicity (World Health Organization criteria) was measured using blood and urine tests of renal, hepatic and bone marrow function. Results  Complete response was achieved in one (5.9%) patient and partial in eight (47.0%), and disease stabilization in 3 (17.7%) patients; five (29.4%) did not respond. A 32-month median survival time was estimated in 12 (70.5%). Nine of these 12 surviving had a mean target diameter shrinkage from 144 ± 81 to 60 ± 59 mm. Grade 1 erythro-, leuko- and thrombo-cytopenia occurred in three (17.6%) cases. Conclusion  In unresectable metastatic liver lesions positive for somatostatin receptors repeated, transhepatic high doses of ¹¹¹In-DTPA-Phe¹-octreotide show an effective therapeutic outcome. Given the locoregional modality character of the administration technique plus the extremely short range of ¹¹¹In Auger and internal conversion electrons emission, no nephro-, liver- or myelo-toxicity has so far been observed.     

Comparison of grey matter and metabolic reductions in frontotemporal dementia using FDG-PET and voxel-based morphometric MR studies

Purpose  The aim of this study was to investigate the regional differences between the morphologic and functional changes in the same patients with frontotemporal dementia (FTD) using statistical parametric mapping and voxel-based morphometry (VBM). Methods  Thirteen FTD patients (mean age, 64.9 years old; mean MMSE score, 17.7), 20 sex-matched Alzheimer’s disease (AD) patients (mean age, 65.0 years old; mean MMSE score, 17.5), and 20 normal volunteers (mean age, 65.2 years old; mean MMSE score, 29.0) underwent both [¹⁸F]FDG positron emission tomography and three-dimensional spoiled gradient echo MRI. Statistical parametric mapping was used to conduct a VBM analysis of the morphologic data, which were compared voxel by voxel with the results of a similar analysis of glucose metabolic data. Results  FTD patients showed decreased grey matter volume and decreased glucose metabolism in the frontal lobe and anterior temporal lobe. In addition, there was a clear asymmetry in grey matter volume in FTD patients by the VBM analysis while the glucose metabolic data showed little asymmetry. In AD patients, glucose metabolic reduction occurred in the bilateral posterior cingulate gyri and parietal lobules while grey matter density decreased the least in the same patients. Conclusion  In FTD, metabolic and morphologic changes occur in the bilateral frontal lobe and temporal lobe with a limited asymmetry whereas there was considerable discordance in the AD group.