H. Stridbeck

Tumor Seeding Occurring after Fine-Needle Biopsy of Abdominal Malignancies

Percutaneous fine-needle aspiration biopsy is a commonly used diagnostic procedure with a high accuracy and a low complication rate. However, tumor seeding in the biopsy tracts has been recorded with a frequency of one in 20 000–40 000 biopsies. We report 5 cases of percutaneous tumor seeding recorded after 5 000 fine-needle biopsies of abdominal malignancies at our institution. The risk of implantation metastases induced by fine-needle biopsy warrants consideration in patients with abdominal malignancies since it may compromise the outcome of radical surgery. It should only be performed when the result of the procedure has a direct impact on the choice of therapy.

Endoscopic Treatment of Bile Duct Calculi in Patients with Gallbladder in Situ Long-Term Outcome and Factors Predictive of Recurrent Symptoms

BACKGROUND Whether endoscopic sphincterotomy (EST) in elderly and/or high-risk patients with common bile duct calculi (CBD) and the gallbladder in situ should be followed by routine cholecystectomy is still a subject of controversy. METHODS To identify factors predictive of subsequent biliary tract symptoms after EST and bile duct clearance, we reviewed 265 patients with intact gallbladder and CBD calculi who were considered for EST in our department from 1981 to 1992. In 15 of 265 patients endoscopic treatment was not carried out, and the records of 4 patients were missing. RESULTS Complete removal of all bile duct calculi failed in 27 patients (11%). Cholecystectomy was performed in 35 patients (16%) with cleared bile ducts 1-765 days (median, 60 days) after EST, in spite of absence of recurrent symptoms from the biliary tract. The remaining 184 patients have been retrospectively followed up for 14-150 months (median, 69 months). Cholecystectomy was required in 35 because of acute cholecystitis (n = 23) or biliary colic (n = 12). Of the cholecystectomies 86% were performed within 24 months after EST and only one after 4 years of follow-up. Increased frequency of cholecystectomy was found in patients with complete opacification of the gallbladder at endoscopic cholangiography (p = 0.005). This was especially evident in patients younger than 80 years (p = 0.002). Cholecystectomy was also required more often in patients with gallbladder calculi (p = 0.02). The risk of cholangitis in patients without recurrent stones was higher in those with juxtapapillary diverticula (p = 0.02). Fifty-nine patients without and 17 with mild to moderate symptoms from the biliary tract died after a median time of 39 and 46 months, respectively. Seventy-three patients are alive, and 59 are symptom-free. Ten patients have had and four still have complaints of mild to moderate biliary tract symptoms. They have been followed for up to 16-146 months (median, 40 months). CONCLUSIONS These findings confirm that endoscopic treatment alone in this group of patients is a feasible treatment principle. Recognition of the registered risk factors might be helpful when selecting patients for subsequent cholecystectomy.

Long-Term Follow-up after Endoscopic Treatment of Bile Duct Calculi in Cholecystectomized Patients

Abstract. Endoscopic sphincterotomy (EST) is an established method for treatment of retained or recurrent common bile duct (CBD) calculi after cholecystectomy. Present experience shows that few patients have recurrent biliary tract complications, but follow-up periods are most often short. EST was performed in 147 patients with bile duct calculi and remote cholecystectomy in our department from 1981 to 1992. In 8 of 147 patients (5.4%) complete removal of calculi failed. A total of 135 patients with a median age of 71 years (range 24–96 years) were eligible for a follow-up of 23 to 153 months (median 86 months). Thirty-seven patients have died without recurrent symptoms (a recurrent stone was revealed at postmortem examination in one patient), and four patients (two with calculi and two with cholangiocarcinoma) died with recurrent symptoms from the biliary tract. Ninety-four patients are alive; and with the exception of two who have had cholangitis without or with post-EST stenosis, respectively, they are all symptom-free. Jaundice, cholangitis, and biliary pancreatitis prior to EST were the only factors that significantly (p = 0.006, Fisher’s exact test) predicted late biliary complications after EST in patients with recurrent calculi. These findings confirm that endoscopic treatment of CBD calculi in cholecystectomized patients has a low long-term rate (5 of 135; 3.7%) of recurrent nonmalignant bile duct disease (three patients with CBD calculi and two with cholangitis).

Collateral circulation following repeated distal embolization of the hepatic artery in pigs.

The distal hepatic arteries of eight pigs were embolized weekly with nondegradable microparticles. Hepatic angiograms were obtained before and after each embolization. One week after the last embolization Microfil was injected into the arterial and portal vascular beds of the liver prior to sacrifice. This study reveals that extensive collateral circulation develops after both primary and repeat embolization. After a third embolization in four of the pigs, the hepatic arterial circulation was almost totally abolished in two pigs with resulting extensive liver necrosis. An intact portal circulation is not sufficient to prevent infarction in dearterialized liver parenchyma.

Enhanced drug retention in VX2 tumors by use of degradable starch microspheres.

Twenty-nine rabbits with 12- to 14-day-old VX2 tumors in the hind leg were injected intraarterially with technetium-99m (99mTc) DTPA and various combinations of biodegradable starch microspheres, Spherex (Pharmacia, Sweden), to evaluate the efficacy of the microspheres in enhancing tumor retention of 99mTc DTPA. A gamma camera and nuclear medicine computer were used to generate time activity curves of 99mTc DTPA concentration in the tumors. Blood flow to the tumor and various muscles was also measured at intervals by left ventricular injection of 15 micron radiolabeled plastic microspheres. Ninety minutes following the administration of 99mTc DTPA, specimens from the tumor, plasma and different muscles were counted in a NaI well counter connected to a multichannel analyzer. When biodegradable microspheres mixed with 99mTc DTPA were injected and followed by a slow infusion of plain starch microspheres, the 99mTc DTPA was retained in the tumor at concentrations up to 11 times that seen when 99mTc DTPA alone was injected; the corresponding biological half-time was 13 times longer than control values. Additionally, the degree of drug retention was inversely related to blood flow, with retention increasing as blood flow decreased. The results have possible applications to the use of biodegradable microspheres in the intraarterial delivery of chemotherapeutic agents to solid tumors.

Electrolytic stents to inhibit tumor growth. An experimental study in vitro and in rats.

Obstruction of metallic stents used in the management of malignant biliary strictures is common and in several cases due to tumor growth through the stent wall. In an experimental animal model in rats, a tumor was implanted subcutaneously adjacent to different metallic stents. Ingrowth of tumor through the wall of these stents was frequent. A stent generating direct electric current on the basis of electrolysis was developed and tested in vitro and in the experimental model. The study confirms that an “electrolytic” stent can inhibit ingrowth of tumor.

Development of collateral circulation following distal embolization of hepatic artery in pigs

The distal hepatic artery was embolized with black polystyrene microspheres (diameters of 50±10 μ and 200±25 μ) in 12 pigs. The animals were reexamined from 1 h to 2 weeks after embolization via hepatic angiography and subsequent injection of Microfil, a silicone rubber compound, into the arterial and portal vascular systems of the liver. Dissection of dehydrated and cleared liver specimens under the stereomicroscope demonstrated the presence of arterial collaterals bypassing embolized vessels within 2–3 days after embolization. Collaterals were noted to develope around occlusions in arteries with inner diameters as small as 100 μ.

Intravascular ultrasound for evaluation of portal venous involvement in pancreatic cancer

Abstract. The aim of this study was to evaluate the accuracy of intravascular ultrasound (IVUS) in diagnosing tumour involvement of the portal vein in patients with exocrine cancer of the head of the pancreas. Seven consecutive patients with a preoperative diagnosis of carcinoma, preoperatively deemed to be resectable, were examined with IVUS of the portal vein during surgery. The IVUS catheters were 6.2 F (2.0 mm) in diameter with a 20-MHz transducer and were introduced into the portal vasculature through the mesenteric superior vein. All patients had tumour extending to the portal vein as demonstrated at histopathological examinations in six cases and at surgical dissection in one case. The IVUS technique correctly identified all these patients, whereas five patients were incorrectly deemed at surgery not to have tumour involvement of the portal vein. These results indicate that IVUS is a very sensitive method for the evaluation of tumour involvement of the portal vein.

Treatment of malignant biliary obstruction by percutaneous transhepatic insertion of expandable metallic stents

A group of 55 patients with jaundice secondary to malignant biliary obstruction were treated with percutaneous transhepatic insertion of self-expandable metal stents (Wallstents). Obstruction was caused by pancreatic carcinoma in 22 patients, cholangiocarcinoma in 21 patients, and other malignancies in 12 patients. A total of 16 patients were treated for hilar obstruction, 35 patients for obstruction of the bile duct below the hilum, and 4 patients for obstruction in a bilioenteric anastomosis. Stent insertion was performed as a two-step procedure in 37 patients, but as a one-step procedure in 18 patients. Adequate bile drainage was achieved in all patients. Procedure-related complications occured in 9 % of cases. After 24 months of observation time 46 patients had died (mean survival 4.6 months). The 30-day mortality rate was 5.5 %. A total of 14 patients (25.5 %) developed recurrent jaundice after an average of 5.3 (0–13) months. Percutaneous insertion of Wallstents ensures good palliation, is relatively safe, and may be performed as a one-step procedure.

Accuracy of CT Arterial Portography of the Liver Compared with Findings at Laparotomy

To evaluate the accuracy of CT arterial portography (CTAP) of the liver, CTAP examinations from 111 patients were retrospectively reviewed and compared with the findings at laparotomy. Laparotomy had been performed within 3 weeks after the CTAP examination. In cases of resectable liver tumor, the result from the pathologic examination report was used to calculate the accuracy of CTAP. In cases of nonresectable liver tumor or liver without tumor, CTAP findings were compared with the result of a thorough inspection and palpation of the liver. The right liver lobe and the medial and lateral segments of the left lobe were separately evaluated. Thus, a total of 333 lobes/segments were evaluated. Tumor was found at laparotomy in 80 of 333 lobes or segments. At CTAP a total of 94 lobes were evaluated as positive for tumor growth, 23 of these were falsely interpreted as positive and 9 were falsely interpreted as negative when compared with the findings at laparotomy. However, 3 patients called false-positives later turned out to be true-positives since the lesions were overlooked at operation. A sensitivity of 89%, a specificity of 91%, and an accuracy of 90% was calculated for CTAP. It is concluded that CTAP has a higher accuracy than other radiologic methods and should be considered suitable for preoperative evaluation of potentially resectable liver tumor.