Campath-1H immunosuppressive therapy reduces incidence and intensity of acute rejection in intestinal and multivisceral transplantation

Campath-1H, an anti-CD52 antibody, is being used at our institution as immunosuppression in multivisceral and intestinal transplantation. We reviewed the pathologic findings of 1696 small bowel allograft biopsies obtained in the first 250 days posttransplant from 78 patients who underwent isolated intestinal or multivisceral transplantation and received induction immunosuppression with Campath (n = 30) or Zenapax (n = 57). We found an overall reduced incidence of acute cellular rejection (ACR) in patients receiving Campath (19.1%) compared with those on Zenapax (32.8%). The majority of Campath patients showed no rejection or was indeterminate for rejection over the period of measurement. The frequencies of mild and moderate ACR were approximately twice and three times more common, respectively, in Zenapax-treated patients. The mean grade of ACR in Campath patients compared with Zenapax patients was significantly lower (P <.01) during the first 6 weeks posttransplant. Thereafter, the grade of rejection in both patient groups showed fluctuation, with Zenapax patients sometimes having lower values (eg, at 2 to 4 months) than Campath patients. Patient and graft survival was not significantly different between the two groups. These data suggest that the incidence of ACR is significantly reduced with Campath during the first 2 months posttransplant, when compared with Zenapax. However, the incidence and intensity of ACR following this initial time period shows vacillation with both types of immunosuppression.     

Active chemotherapy with gemcitabine, carboplatin and docetaxel for three patients with MVAC-resistant liver metastasis of urothelial carcinoma

We report three cases with methotrexate-vinblastin-adriamycin-cisplatin (MVAC) resistant multiple liver metastases of urothelial carcinoma that responded to combination chemotherapy consisting of gemcitabine plus carboplatin (GC) with additional docetaxel (GCD) as salvage chemotherapy. Case 1: A 55-year-old man underwent left nephroureterectomy for ureteral cancer (TCC, G3, pT3pN1M0). Three courses of GC followed by three courses of GCD were given via intra-hepatic arterial infusion for multiple liver metastases, which appeared after adjuvant high-dose MVAC therapy. Complete response was obtained and maintained for 11 months. Case 2: A 46-year-old man underwent radical cystectomy for locally advanced bladder cancer (TCC G3 + adenocarcinoma. pT3pN0M0). Two courses of GC followed by 2 courses of GCD systemic therapies were performed for multiple liver metastases, which appeared after adjuvant high-dose MVAC therapy. Partial response was obtained and maintained for six months. Case 3: A 66-year-old man received three courses of MVAC for multiple metastases of the bladder cancer (TCC, G3, > pT2), which resulted in disease progression. Eight courses of GC followed by six courses of GCD were administrated via intra-hepatic arterial infusion. Partial response was obtained and maintained for 12 months. Although the response duration was still short, GC and GCD may be promising salvage chemotherapeutic regimens for the patients with MVAC-resistant liver metastases of urothelial carcinoma.     

Epidural hematoma after an epidural block in a patient with no coagulopathy

We report a case of epidural hematoma after a single epidural block. The patient was a 67-year-old woman with sciatica and osteoarthritis of the spine. She had no coagulopathy. She underwent a single epidural block without difficulty 3 times in 5 days. She had a lumbar MRI for an examination of the spine 4 days after the final epidural block. Subacute epidural hematoma of 0.8 x 1.5 x 3.0 cm was revealed on MRI at L 3-4. She had no new neurological symptoms. MRI 1 month later revealed a resolution of the hematoma. Epidural hematoma after an epidural block might occur in an outpatient with no bleeding tendency.     

A case of organ sparing surgery for metachronous bilateral testicular tumor with maintaining testicular function

A 28-year-old man, who had undergone right orchiectomy and prophylactic irradiation for stage I seminoma 6 years ago, developed left testicular tumor. Since the secondary tumor was localized in the lower pole of the testis, partial orchiectomy was performed with an attempt to preserve the testicular function. The pathological finding of the surgical specimen was a mixed type testicular tumor consisting of seminoma, embryonal carcinoma and teratoma elements. Postoperative chemotherapy with 3 courses of BEP regimen resulted in azoospermia, but the impaired spermatogenesis recovered to a normal range within 18 months with no evidence of tumor recurrence and his wife delivered a healthy baby 2 years later. For the synchronous or metachronous bilateral testicular tumors, the combination of organ sparing surgery and chemotherapy could be a treatment of choice.     

Intracranial atypical fibromuscular dysplasia with ruptured aneurysm--case report

A 53-year-old woman was admitted with severe subarachnoid hemorrhage due to rupture of an aneurysm associated with atypical intracranial fibromuscular dysplasia (FMD). Angiography demonstrated the aneurysm and very irregular form of the left internal carotid artery (ICA), the right ICA, and right proximal middle cerebral artery (MCA). Other arteries showed signs of atherosclerosis. The aneurysm was treated by embolization, but she subsequently died of shock of unknown cause. Detailed examination of serial angiograms detected enlargement of the aneurysm and progression of the irregular appearance of the ICA. FMD is a non-inflammatory and non-atheromatous arteriopathy that commonly affects the cervical ICA and sometimes the intracranial ICA. The association with saccular aneurysm is widely known and the prevalence of incidental aneurysms is higher than that in the general population. The common "string of beads" finding is easily distinguished from other vascular diseases, but non-specific findings such as "tubular stenosis" and "diverticular-like outpouching" are harder to differentiate. FMD is associated with various complications and appropriate periodic follow-up examination is required. Detailed analysis of serial angiograms may facilitate diagnosis of this condition.     

A simplified method for continuous hepatic arterial port-catheter system placement not requiring catheter end-hole occlusion

Purpose: To evaluate the efficacy of hepatic port-catheter system placement without distal catheter tip occlusion or gastroduodenal artery embolization distal to the catheter tip.

Material and Methods: A port-catheter system was percutaneously implanted in 29 patients (16 men, 13 women; mean age 65.6 years) with unresectable liver cancer. Persistent blood flow through the end hole of the catheter was verified immediately and 1-10 days after catheter placement.

Results: In all cases, percutaneous port-catheter placement was successfully performed. In seven of 29 (24.1%) patients, flow through the end hole of the catheter was verified immediately after the procedure. However, no flow was seen 1-10 days after the procedure.

Conclusion: It is not necessary to occlude the end hole of the catheter tip and embolize the gastroduodenal artery beyond the catheter tip when placing a port-catheter system for repeated hepatic arterial infusion chemotherapy.     

Carotid artery stenting for stenosis with intraluminal thrombus

Since intraluminal thrombus in the context of carotid artery stenosis is rarely encountered, treatment for this condition remains controversial. The present paper describes six cases of carotid artery stenosis with thrombus and discusses the efficacy and complications of carotid artery stenting (CAS). From April 2002 to May 2004, six patients with carotid artery stenosis and intraluminal thrombus receiving medical therapy underwent CAS at our institution. CAS was performed with distal protection alone (method 1) in three patients, and three other patients underwent CAS with reversed-flow system and distal protection (method 2). Two of six patients experienced worsening neurologic symptoms despite medical therapy. All six patients were successfully treated with CAS and showed satisfactory patency of the artery. Embolic lesions were detected on diffusion-weighted MRI after the procedure in all patients treated with method 1 but not in patients treated with method 2. Complications included stent thrombosis (n=1) and in-stent thrombus (n=1). All six patients achieved a modified Rankin Scale 1 or 2 classification at 30 days after stenting. In conclusion, CAS was feasible for stenosis even with intraluminal thrombus. Use of method 2 for this condition may reduce the incidence of thromboembolic events although our series was small in number.     

Thymic epithelial tumors: comparison of CT and MR imaging findings of low-risk thymomas, high-risk thymomas, and thymic carcinomas

OBJECTIVE: To assess the CT and magnetic resonance (MR) imaging findings of thymic epithelial tumors classified according to the current World Health Organization (WHO) histologic classification and to determine useful findings in differentiating the main subtypes. MATERIALS AND METHODS: Sixty patients with thymic epithelial tumor who underwent both CT and MR imaging were reviewed retrospectively. All cases were classified according to the 2004 WHO classification. The following findings were assessed in each case on both CT and MRI: size of tumor, contour, perimeter of capsule; homogeneity, presence of septum, hemorrhage, necrotic or cystic component within tumor; presence of mediastinal lymphadenopathy, pleural effusion, and great vessel invasion. These imaging characteristics of 30 low-risk thymomas (4 type A, 12 type AB, and 14 type B1), 18 high-risk thymomas (11 type B2 and seven type B3), and 12 thymic carcinomas on CT and MR imaging were compared using the chi-square test. Comparison between CT and MR findings was performed by using McNemar test. RESULTS: On both CT and MR imaging, thymic carcinomas were more likely to have irregular contours (P < .001), necrotic or cystic component (P < .05), heterogeneous contrast-enhancement (P < .05), lymphadenopathy (P < .0001), and great vessel invasion (P < .001) than low-risk and high-risk thymomas. On MR imaging, the findings of almost complete capsule, septum, and homogenous enhancement were more commonly seen in low-risk thymomas than high-risk thymomas and thymic carcinomas (P < .05). MR imaging was superior to CT in the depiction of capsule, septum, or hemorrhage within tumor (all comparison, P < .05). CONCLUSION: The presence of irregular contour, necrotic or cystic component, heterogeneous enhancement, lymphadenopathy, and great vessel invasion on CT or MR imaging are strongly suggestive of thymic carcinomas. On MR imaging, the findings of contour, capsule, septum, and homogenous enhancement are helpful in distinguishing low-risk thymomas from high-risk thymomas and thymic carcinomas.     

Pancreatic adenocarcinoma: MDCT versus MRI in the detection and assessment of locoregional extension

PURPOSE: To compare dynamic-contrast enhanced multirow detector computed tomography (MDCT) including multiplanar reformatted images (MPR) and magnetic resonance imaging (MRI) including magnetic resonance cholangiopancreatography images for the detection and assessment of locoregional extension of pancreatic adenocarcinoma. MATERIALS AND METHODS: Twenty-four patients with and 21 patients without pancreatic adenocarcinoma underwent triple-phase MDCT and MRI. Three radiologists independently attempted to detect pancreatic adenocarcinoma and assess locoregional extension in 3 sessions. First session involved MDCT images. In the second session, radiologists had access to coronal and sagittal MPR images together with the axial images (MDCT + MPR). Third session involved MR images. Results were compared with surgical findings using receiver operating characteristic analysis and kappa statistics. RESULTS: Regarding tumor detection, MDCT + MPR had a significantly higher value for areas under the curve (0.96 +/- 0.02) at receiver operating characteristic analysis compared with those of MRI (0.90 +/- 0.03) and MDCT (0.85 +/- 0.04). MDCT + MPR had the highest mean sensitivity (96%), and MRI had the highest mean specificity (98%). For locoregional extension, MDCT + MPR showed the highest kappa values of the study for all factors evaluated (range, 0.63-0.86). CONCLUSIONS: In conclusion, multiphasic MDCT imaging with MPR images was superior to multiphasic MDCT imaging without MPR images and to comprehensive MRI employing 2-D sequences and magnetic resonance cholangiopancreatography for both the detection and assessment of locoregional extension of pancreatic adenocarcinomas. MRI might be used for further lesion characterization regarding its high specificity.