Fabrizio Chegai

Kidney Transplant: Usefulness of Real-Time Elastography (RTE) in the Diagnosis of Graft Interstitial Fibrosis

The aim of this study is to evaluate the usefulness of real-time elastography (RTE) in the diagnosis of graft interstitial fibrosis. We prospectively enrolled 50 patients clinically suspected of graft fibrosis. RTE was performed with a broadband linear transducer using a dedicated ultrasound machine. Tissue mean elasticity (TME) was calculated by two blinded operators. All patients underwent biopsy after RTE. To determine cortical fibrosis Banff score was used. The receiver operating characteristic curves analysis was performed to evaluate the accuracy of TME to discriminate between patients with mild fibrosis (F1) versus patients with moderate to severe fibrosis (F2-F3). Inverse correlation between TME values and the degree of fibrosis has been shown (p < 0.05). Patients with F1 had mean TME values significantly higher compared with TME in patients with F2 (p = 0.005) and F3 (p = 0.004). The diagnostic accuracy of TME measurement for F2-F3 evaluated by area under the curve-receiver operating characteristic analysis was 0.95. RTE was able to evaluate kidney fibrosis in a non-invasive way and could be used as complementary imaging during follow-up of renal transplant patients.

DWI of Prostate Cancer: Optimal b-Value in Clinical Practice.

Aim. To compare the diagnostic performance of diffusion weighted imaging (DWI) using b-values of 1000 s/mm2 and 2000 s/mm2 at 3 Tesla (T) for the evaluation of clinically significant prostate cancer. Matherials and Methods. Seventy-eight prostate cancer patients underwent a 3T MRI scan followed by radical prostatectomy. DWI was performed using b-values of 0, 1000, and 2000 s/mm2 and qualitatively analysed by two radiologists. ADC maps were obtained at b-values of 1000 and 2000 s/mm2 and quantitatively analyzed in consensus. Results. For diagnosis of 78 prostate cancers the accuracy of DWI for the young reader was significantly greater at b = 2000 s/mm2 for the peripheral zone (PZ) but not for the transitional zone (TZ). For the experienced reader, DWI did not show significant differences in accuracy between b-values of 1000 and 2000 s/mm2. The quantitative analysis in the PZ and TZ was substantially superimposable between the two b-values, albeit with a higher accuracy with a b-value of 2000 s/mm2. Conclusions. With a b-value of 2000 s/mm2 at 3T both readers differentiated clinical significant cancer from benign tissue; higher b-values can be helpful for the less experienced readers.

Hepatocellular Carcinoma and Diffusion-Weighted MRI: Detection and Evaluation of Treatment Response

Differentiating between cancerous tissue and healthy liver parenchyma could represent a challenge with the only conventional Magnetic Resonance (MR) imaging. Diffusion weighted imaging (DWI) exploits different tissue characteristics to conventional Magnetic Resonance Imaging (MRI) sequences that enhance hepatocellular carcinoma (HCC) detection, characterization, and post-treatment evaluation. Detection of HCC is improved by DWI, infact this technology increases conspicuity of lesions that might otherwise not be identified due to obscuration by adjacent vessels or due to low contrast between the lesion and background liver. It is important to remember that DWI combined with contrast-enhanced MRI has higher sensitivity than DWI alone, and that some patients are not eligible for use of contrast on CT and MRI; in these patients DWI has a prominent role. MRI has advanced beyond structural anatomic imaging to now showing pathophysiologic processes. DWI is a promising way to characterize lesions utilizing the inherent contrast within the liver and has the benefit of not requiring contrast injection. DWI improves detection and characterization of HCC. Proposed clinical uses for DWI include: assessing prognosis, predicting response, monitoring response to therapy, and distinguishing tumor recurrence from treatment effect. Ideally, DWI will help risk stratify patients and will participate in prognostic modeling.

Foot Embolization During Limb Salvage Procedures in Critical Limb Ischemia Patients Successfully Managed With Mechanical Thromboaspiration: A Technical Note.

Purpose: To illustrate the use of a mechanical thromboaspiration device originally designed for clot retrieval in acute stroke in the treatment of acute distal embolism occurring during percutaneous revascularization of the femoropopliteal and below-the-knee arterial segments. Technique: The Penumbra system was adapted for aspiration of thrombus in the distal foot arteries as a standalone device. The 2 over-the-wire, tapered lumen catheters have long working lengths (139 cm for the 4MAX to 153 cm for the 3MAX) that allow advancement below the ankle even with a retrograde contralateral approach. Once the occluded arterial segment is reached, the catheters are connected to the dedicated pump for continuous vacuum aspiration. The use of the device is illustrated in 3 diabetic patients (1 woman and 2 men; ages 88, 70, and 73 years, respectively) undergoing limb salvage procedures who experienced distal embolization that would have seriously jeopardized the foot circulation. The lumens of the occluded arteries were restored without complication. Conclusion: While further evaluation in a larger cohort of patients is needed, this initial experience using the Penumbra system in the peripheral vasculature suggests that this is a rapid, effective approach to address intraprocedural foot embolization and avoid possible grave clinical sequelae.

Downstaging disease in patients with hepatocellular carcinoma outside up-to-seven criteria: Strategies using degradable starch microspheres transcatheter arterial chemo-embolization.

AIM To evaluate the downstaging rates in hepatitis C virus-patients with hepatocellular carcinoma (HCC), treated with degradable starch microspheres transcatheter arterial chemoembolization (DSM-TACE), to reach new-Milan-criteria (nMC) for transplantation. METHODS This study was approved by the Ethics Committee of our institution. From September 2013 to March 2014 eight patients (5 men and 3 women) with liver cirrhosis and multinodular HCC, that did not meet nMC at baseline, were enrolled in this study. Patients who received any other type of treatment such as termal ablation or percutaneous ethanol injection were excluded. DSM-TACE was performed in all patients using EmboCept(®) S and doxorubicin. Baseline and follow-up computed tomography or magnetic resonance imaging was assessed measuring the longest enhancing axial dimension of each tumor according to the modified Response Evaluation Criteria In Solid Tumors measurements, and medical records were reviewed. RESULTS DSM-TACE was successfully performed in all patients without major complication. We treated 35 lesions (mean 4.3 per patient). Six of eight patients (75%) had their HCC downstaged to meet nMC. Every patient whose disease was downstaged eventually underwent transplantation. The six patients who received transplant were still living at the time of this writing, without recurrence of HCC. Baseline age (P = 0.25), Model for End-stage Liver Disease score (P = 0. 77), and α-fetoprotein level (P = 1.00) were similar between patients with and without downstaged HCC. CONCLUSION DSM-TACE represents a safely and effective treatment option with similar safety and efficacy of conventional chemoembolization and could be successfully performed also for downstaging disease in patients without nMC, allowing them to reach liver transplantation.

Radiofrequency Thermoablation of HCC Larger Than 3 cm and Less Than 5 cm Proximal to the Gallbladder without Gallbladder Isolation: A Single Center Experience

Radiofrequency ablation (RFA) is an effective minimally invasive treatment for nonsurgical hepatocellular carcinoma (HCC), but ablation of tumors close to the gallbladder could be associated with several complications. We report our experience on the treatment of HCC close to the gallbladder with RFA. Eight RFA procedures were performed in eight patients with HCC larger than 3 cm and less than 5 cm close to the gallbladder. In all cases, a percutaneous approach was used. There were no major complications. Only in two patients a minimal wall thickening of the gallbladder was observed. Contrast enhanced computed tomography carried out after 30 days from the first procedure showed complete necrosis in seven patients (87%). Only one patient had local recurrence at 11 months of followup. Although limited, our experience suggests that, after careful preprocedural planning, in experienced hands and with appropriate technology, percutaneous RFA could be safely performed even for lesions larger than 3 cm located in close adjacency to the gallbladder.

Re: Baseline and Early MR Apparent Diffusion Coefficient Quantification as a Predictor of Response of Unresectable Hepatocellular Carcinoma to Doxorubicin Drug-Eluting Bead Chemoembolization

From: Fabrizio Chegai, MD Stefano Merolla, MD Laura Greco, MD Marco Nezzo, MD Lorenzo Mannelli, MD, PhD Antonio Orlacchio, MD Department of Diagnostic and Molecular Imaging, Radiation Therapy and Interventional Radiology (F.C., S.M., L.G., M.N., A.O.) University Hospital Tor Vergata Viale Oxford 88 001133 Rome, Italy; and Department of Radiology (L.M.) Memorial Sloan–Kettering Cancer New York, New York

Trans-splenic Embolization Plus Partial Splenic Embolization for Management of Variceal Bleeding Due to Left-Sided Portal Hypertension

Bleeding from gastric fundal varices (GFVs) is generally less frequent but more severe than bleeding from esophageal varices [1], and currently a gold standard treatment does not yet exist. The presence of GFVs without esophageal varices could be a sign of splenic vein occlusion because blood drainage is diverted by the coronary vein into the portal system within a framework of so-called left-sided portal hypertension (LSPH) [2]. Often LSPH may be due to iatrogenic splenic vein injury or ligation [3]. The importance of differentiating between left-sided and generalized portal hypertension lies in the distinct therapeutic management of each disease process. In the patient described here, since it proved impossible to achieve a safe and effective embolization throughout a previously placed TIPS that did not allow gastric veins (GVs) decompression, a percutaneous trans-splenic embolization (PTSE) of GFVs and two partial splenic embolizations (PSEs) were performed with the aim to reduce the splenic venous outflow. Case Report

Repeated Transarterial Chemoembolization with Degradable Starch Microspheres (DSMs-TACE) of Unresectable Hepatocellular Carcinoma: A Prospective Pilot Study

Objective: The aims of this study were to: a) evaluate tumor response rates using modified-Response-evaluation-criteria-in-solid-tumors (mRecist) criteria, b) evaluate safety of Degradable Starch Microspheres Trans-arterial-chemo-embolization (DSMs-TACE) for unresectable hepatocellular-carcinoma (HCC) treatment. Materials and Methods: We prospectively enrolled 24 HCC cirrhotic patients (21/3 M/F, mean age 66.3 years) to be treated with repeated DSMs-TACE procedures, performed at 4-6 week intervals on the basis of tumor response and patients tolerance. Clinical and biochemical evaluations were performed before and after each procedure. Treatment response was also assessed by Computed-tomography (CT) or Magnetic-resonance-imaging (MRI)-scan 4-6 weeks following each procedure. Results: In our experience, DSMs-TACE was both safe and effective. A total of 53 DSMs-TACE procedures were performed (2.2 per patient). No procedure-related death was observed. Complete Response (CR) was observed in 5/24 (20.8%), 4/17 (23.5%) and 5/12 (41.6%) patients after the first, second and third procedure, respectively. At the end of each treatment, all patients experienced at least a partial response. At the end of the repeated procedures, no differences between mono- or bi-lobar disease were observed in patients with CR (64.2% vs 50%; p=ns). In most cases, treatment discontinuation was due to worsening liver function. Conclusion: DSMs-TACE is a valid, well-tolerated alternative treatment to Lipiodol-TACE or DEB-TACE, as it has demonstrated to achieve a relatively high percentage of complete tumor necrosis. CR rates were similar between patients with mono- or bi-lobar disease indicating the possibility of carrying-out repeated procedure in a safe and effective way in both types of patients.

Intraprocedural Foot Embolization during In-Stent Restenosis Superficial Femoral Artery Recanalization: Plantar to Pedal Loop Aspiration Thrombectomy Technique Using the Penumbra MAX Catheter

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