Elias Primetis

Transcatheter arterial embolization as therapy of renal angiomyolipomas: The evolution in 15 years of experience

OBJECTIVE This study aims at presenting the evolution of the embolization technique in treating renal angiomyolipomas (AMLs) either diagnosed in patients with acute bleeding or discovered accidentally. METHODS Ten patients with renal AMLs have been through thirteen selective transcatheter arterial embolizations for 15 years. Two patients had tuberous sclerosis complex (TSC) with bilateral tumors and were embolized twice. Four embolic materials were employed: PVA particles, Gianturco coils, microspheres and microcoils. Catheterization was achieved by means of 5F Cobra 2 catheters and coaxial microcatheter systems. RESULTS On an emergency basis, embolization was a first-line treatment. In one case, surgery was necessary; in two patients, a second embolization was performed. When treatment was preventive, a single embolization proved to be sufficient, as well. There was no significant deterioration of the serum creatinine levels in the post-embolization period. CONCLUSION Selective arterial embolization is a rather safe and effective technique to treat AMLs both urgently and preventively. Different embolic materials can be employed. Microspheres and microcatheters stand for new promising materials.

Iliopsoas: a new electromyographic technique and normal motor unit action potential values.

OBJECTIVE To describe a reliable technique of needle electrode examination and present the normal values of motor unit action potential (MUAP) parameters in iliopsoas muscle. METHODS Thirty-one normal subjects underwent quantitative electromyographic (QEMG) examination of the iliopsoas muscle, following an ultrasonographically confirmed technique of needle electrode insertion and sampling. The leg under examination was flexed, abducted and externally rotated at the hip joint and also flexed at the knee joint. A slight flexion at the hip joint was used to uncover iliopsoas from the overlying sartorius. This provides enough space at the inguinal region between the sartorius and the femoral neurovascular bundle. Mean and outlier values of MUAP parameters and polyphasia were calculated. RESULTS Our technique was easy to perform and secure in sampling iliopsoas. The mean +/- SD values for MUAP duration, amplitude, area, area to amplitude ratio, phases and turns were 11.5 +/- 1.35 ms, 419 +/- 71.5 microV, 633 +/- 142.7 microV ms, 1.57 +/- 0.25, 3.1 +/- 0.32, and 2.9 +/- 0.44, respectively. Lower and upper outlier limits for duration, amplitude, area and area to amplitude ratio were 3.6/20.7 ms, 150/930 microV, 100/1567 microV ms, and 0.35/3.07. Mean polyphasia was 12.6% (range 0-30%). CONCLUSIONS The suggested EMG technique helped to distinguish iliopsoas from sartorius and at the same time increased the accessibility of its anterior surface. Normal values and outlier limits of the MUAP parameters of iliopsoas have been quantitatively established. SIGNIFICANCE This new technique and the normal MUAP values might prove helpful for the examination of iliopsoas, important in the assessment of many neuropathic and, especially, myopathic processes.

Diagnostic and Therapeutic Challenges of Intrahepatic Biliary Cystadenoma and Cystadenocarcinoma: A Report of 10 Cases and Review of the Literature.

The objective of this study was to present our experience with intrahepatic biliary cystadenomas and cystadenocarcinomas in 10 patients surgically managed in our department. Intrahepatic biliary cystadenomas and cystadenocarcinomas are rare cystic tumors that are often misdiagnosed preoperatively as simple cysts or hydatid cysts. They recur after incomplete resection and entail a risk of malignant transformation to cystadenocarcinoma. A retrospective review was conducted of patients with histologically confirmed intrahepatic biliary cystadenomas and cystadenocarcinomas between August 2004 and February 2013 who were surgically managed in our department. A total of 10 patients, 9 female and 1 male (mean age, 50 years), with cystic liver were reviewed. The size of the cysts ranged between 3.5 and 16 cm (mean, 10.6). Five patients had undergone previous interventions elsewhere and presented with recurrences. Liver resections included 6 hepatectomies, 2 bisegmentectomies, 1 extended right hepatectomy, and 1 enucleation due to the central position and the large size of the lesion. Pathology reports confirmed R0 resections in all cases. All patients were alive after a median follow-up of 6 years (range, 1-10 years), and no recurrence was detected. Intrahepatic biliary cystadenoma and cystadenocarcinoma should be considered in differential diagnosis in patients with liver cystic tumors. Because of the high recurrence rate and difficult accurate preoperative diagnosis, formal liver resection is mandatory. Enucleation with free margins is an option and is indicated where resection is impossible.

Granuloma Mimicking Local Recurrence on PET/CT after Liver Resection of Colorectal Liver Metastasis: A Case Report

Positron emission tomography–computed tomography (PET/CT) improves the diagnostic interpretation of fluorine-18 fluorodeoxyglucose (18F-FDG ) PET and CT in oncologic patients and has an impact on both diagnostic and therapeutic aspects of patient management. However, false positive findings from the PET/CT imaging should be taken into consideration as they mislead physicians into improper therapeutic actions. We present a 48-year-old female patient with a history of left colectomy for colorectal cancer and subsequent liver metastasectomy. After one year of follow-up, she presented with a highly suspicious lesion in the liver, which was confirmed on PET/CT as a metastatic liver tumor. Consequently, the patient underwent surgical excision of the tumor, and the definitive histological diagnosis showed a granulomatous tissue with giant cells and foreign body tissue reaction. Based on this report, we briefly review the dangerous pitfalls from radiological and PET/CT imaging concerning the preoperative diagnostic workup examination, as they may significantly alter the treatment plan in oncologic patients.

Neuroendocrine differentiation in embryonal type hepatoblastoma

Hepatoblastoma, a malignant tumor which arises occasionally in older children but very rarely in adults, exhibits divergent differentiation with embryonal cells, fetal hepatocytes and immature elements. This report describes an embryonal type hepatoblastoma with neuroendocrine differentiation in a 16‐year‐old patient, which was diagnosed postoperatively. Clinical and radiologic work‐up failed to reveal a primary gastrointestinal malignancy and no primary lesions were detected in any other organ. This feature of hepatoblastoma is considered to be a multidirectional differentiation of the small epithelial or stem cells of the liver. At 2‐year follow up, the patient remains symptom‐free, with normal laboratory and diagnostic imaging studies, and no recurrent or metastatic disease identified.

Immune-related intestinal pseudo-obstruction associated with nivolumab treatment in a lung cancer patient:

Immune checkpoint inhibition therapy using targeted monoclonal antibodies is a new therapeutic approach with significant survival benefit for patients with several cancer types. However, their use can be associated with unique immune-related adverse effects as a consequence of impaired self-tolerance due to loss of T-cell inhibition via a nonselective activation of the immune system. Nivolumab is an anti-PD-1 immune checkpoint inhibitor that was recently developed for cancer immunotherapy with remarkable responses in nonsmall cell lung cancer patients. We present a 62-year-old Caucasian male with recurrent lung adenocarcinoma and currently under third-line therapy with nivolumab, who was admitted in our hospital with abdominal distension. Radiologic findings were consistent with small bowel ileus. After four days of conservative treatment, the patient underwent exploratory laparotomy where no cause of ileus was discovered. Postoperative the ileus persisted and considering that an adverse effect of the immune checkpoint inhibition therapy occurred, the patient received high-dose prednisone resulting in gradual improvement of symptoms. Immune checkpoint inhibitors may induce adverse effects to unaffected organ systems and tissues including the skin, gastrointestinal, hepatic, pulmonary, and endocrine system. The mainstay treatment consists of immunosuppression with corticosteroids in the majority of cases. As the clinical use of immune checkpoint inhibitors is expanding rapidly, there is an emergence of unique immune-related adverse effects in a growing patient population. Gaining early awareness is essential in these patients in order to ensure prompt diagnosis and management.

Biliary Mucinous Cystic Neoplasm of the Liver with Ovarian Stroma and Elevated Serum and Cystic Fluid Cancer Antigen 19-9 Levels

Biliary mucinous cystic neoplasms of the liver are rare cystic tumors comprising less than 5% of the liver cystic neoplasms. These tumors demonstrate a female predominance and entail a risk of malignant transformation. We present a 56-year-old female patient with a multiloculated liver cystic lesion measuring 22 cm who underwent a cystectomy with en bloc resection of the liver segments II, III, and cholecystectomy. Serum cancer antigen 19.9 was 4,122.00 U/ml, supporting the diagnosis of a biliary cystic tumor. The cytology of the cystic fluid was negative for malignancy and intracystic fluid cancer antigen 19.9 level was measured over 12,000.00 U/l. The patient is free of recurrence at one-year follow up. Although a rare entity, the biliary mucinous cystic neoplasms should be considered in the differential diagnosis in the patients with liver cystic tumors. The appropriate management with complete surgical resection with negative margins is recommended given the risk of recurrence and malignant transformation.

Congenital Bronchial Atresia with a Calcified Mucocele

Chest CT confirmed the presence of a branching calcified lesion in the apicoposterior bronchus of the left upper lobe ( fig. 2 ). Distal to the lesion, the lung parenchyma appeared hyperinflated with sparse vascularity. Imaging findings were consistent with congenital bronchial atresia with a calcified mucocele. Two years later, follow-up chest CT did not show any changes while the patient remained asymptomatic. Diagnosis of congeniA 31-year-old female was referred to our department to further evaluate an abnormal finding of a routine chest X-ray. She had a 5 pack-year smoking history, no history of lower respiratory tract infection or other pulmonary disease, and no constitutional symptoms. Physical examination was unremarkable. Chest X-ray ( fig. 1 ) revealed a lobulated branching opacity with distal hyperinflation in the left upper lobe. Published online: March 26, 2011

MRI findings of subcutaneous malignant fibrous histiocytoma adjacent to the lateral aspect of the knee

Abstract A case of a surgically confirmed subcutaneous malignant fibrous histiocytoma adjacent to the lateral aspect of the knee in a 64-year-old woman is presented. MR? findings, classification according to the relationship to the superficial fascia and differential diagnosis are discussed.