Marc L. Friedman

The role of embolization in reducing the complications of cryoablation in renal cell carcinoma

AIM To investigate whether embolization prior to cryoablation would decrease morbidity without negative effects on tissue pathology, renal function, or recurrence. MATERIAL AND METHODS The electronic medical records of all patients undergoing cryoablation for renal cell carcinomas were reviewed for lesion size, pre-ablative renal function, post-ablative renal function, post-ablative complications, recurrence, and quality of biopsy specimen. Comparisons were made between patients who underwent cryoablation (the Cryo-Only group) and those who underwent cryoablation after same-day coil embolization of their lesion (the Cryo-Embo group). Further comparison was made between the Cryo-Embo lesions and the subset of larger Cryo-Only lesions (≥ 3 cm), which were expected to have a higher natural complication rate. RESULTS A total of 21 lesions in 19 patients were treated by percutaneous cryoablation (17 Cryo-Only, four Cryo-Embo). Complications were seen in 83% of the large Cryo-Only lesions (average size 3.6 cm), whereas no complication was seen amongst Cryo-Embo lesions (average size 4 cm). Embolization significantly decreased complications between size-matched lesions (p = 0.048) without impacting renal function (p = 1), biopsy quality (p = 1), or recurrence (p = 1). CONCLUSION Performance of trans-arterial embolization prior to cryoablation of large renal cell carcinomas significantly decreases complications, such as haemorrhage, without a discernible effect on biopsy quality, renal function, or recurrence rate.

Radioembolization for treatment of liver metastases from neuroendocrine tumors: correlation with imaging and biomarkers.

To the Editor: In their article ‘‘Long-Term Clinical and Imaging Follow-up of Nonoperated Branch Duct Form of Intraductal Papillary Mucinous Neoplasms of the Pancreas’’, Arlix et al. state that branch duct IPMNs with no signs of malignancy should be managed conservatively. In their 10-year prospective study, none of the patients developed malignancy (n = 49 patients). In contrast, predominantly main duct or mixed forms of IPMNs should be reviewed for surgery due to its high risk of neoplastic transformation. We would like to point out that even in high volume centers and by the use of modern abdominal imaging, it remains difficult to reliably differentiate between IPMNs of the main duct and branch duct type. Furthermore, there exist an increasing number of reports indicating that also in small BD-IPMNs there is a significant risk of malignancy. In our own series, in a large proportion of small (‘‘Sendai negative’’) BD-IPMNs, high-grade dysplasia or frank invasive carcinoma was diagnosed on final histological examination (incidence 25%). With regard to the data of Arlix et al., an increase in cyst size or main pancreatic duct dilation was observed in 18/47 patients which led to surgical resection in 5 patients. It is conceivable that in some of the remaining 13 patients with cyst size progression over time, neoplastic changes could be found histologically. Indeed, Arlix et al. found borderline lesions in 4/5 patients who underwent surgery. It is also possible that some of the lesions observed in this study were rather pseudocysts due to acute or chronic pancreatitis than mucinous cystic neoplasms. Particularly, as the authors report that IPMNs frequently occur in patients with acute pancreatitis. In our opinion, all IPMNs (including the branch duct type) have to be considered as potential precursors to invasive adenocarcinoma. Thus, close follow-up or surgical pancreatic resection are warranted in most cases. ACKNOWLEDGMENT The authors declare no conflict of interest.

Embolization of portosystemic shunts for treatment of medically refractory hepatic encephalopathy: Letters to the Editor

We read with great interest the study by Lynn et al. in Liver Transplantation. The authors reported a 92% hepatic encephalopathy (HE)–free rate in patients at 612 months after portosystemic shunt (PSS) embolization. Their study included 2 patients who had undergone transplantation, one of whom received sustained benefit, whereas the other developed allograft dysfunction and recurrent HE. Below, we report a case of a patient who underwent PSS embolization for HE after orthotopic liver transplantation (OLT), without complications and who no longer requires medical therapy for HE. A 60-year-old patient with hepatitis C cirrhosis and hepatocellular carcinoma underwent OLT on May 11, 2015. Four months afterward, he was hospitalized with altered mental status. After a negative workup including head computed tomography scan, electroencephalography, and infection testing, combined with an elevated ammonia level of 128 mcmol/L, a diagnosis of hepatic encephalopathy was considered. He was treated with lactulose, which improved his mental status, and he was discharged home. Given the uncertainty surrounding the diagnosis of HE, he was not instructed to take lactulose at home. The patient was readmitted 5 days afterward with another episode of HE. Ammonia level on presentation was 131 mcmol/ L, and he again received lactulose with resolution of encephalopathy. Blood tests demonstrated a normally functioning allograft, and liver biopsy demonstrated stage 0 fibrosis. However, a review of his pre-OLT imaging revealed a large splenorenal shunt. Transhepatic splenoportography revealed hepatofugal flow into the splenorenal shunt and no appreciable filling of intrahepatic portal vein branches. The hepatic venous pressure gradient, measured during his transjugular liver biopsy, was 1mm Hg. The patient was counseled regarding the findings and treatment options. Given the severity of side effects he experienced with lactulose, he stated that he could not take this medication on a daily basis. Additionally, he could not receive rifaximin due to the expense of this medication. Therefore, it was decided to proceed with embolization of the splenorenal shunt, which successfully reestablished hepatopetal flow (Fig. 1). Subsequently, lactulose was discontinued, and the patient no longer had symptoms of HE. After 7 months of follow-up, he remains symptom-free without need for lactulose and with normal allograft function. Our case illustrates that when managing HE after OLT, a PSS should be considered as an etiology, either due to shunting which existed prior to OLT or to the development of a PSS de novo after OLT, due to, for instance, increased intrahepatic vascular resistance secondary to acute cellular rejection. Furthermore, we report that embolization of PSS was safe and effective after OLT in our patient and can be considered as a therapeutic option for HE occurring after liver transplantation.

Transjugular Liver Biopsy in a Patient with a Total Artificial Heart

was repaired, and the patient was discharged home 2 days after the procedure. Surgical retrieval of a retained needle in the perineum assisted by the placement of a hook wire using biplane fluoroscopy has also been reported by Kleinpeter et al (3). However, in our experience, CT afforded an acceptable alternative with potentially more accurate localization and superior delineation of adjacent structures. Exploratory dissection for retained surgical instruments can be a frustrating and challenging endeavor. Hook wire localization can result in direct access for the surgeon without the need for an extensive dissection. CT guidance for localization improves the precision and reliability of the hook wire placement, particularly in deep structures that are not easily visualized with

The Clinicopathological Aspects of Primary Presacral Neuroendocrine Neoplasms: One Center Experience

Objectives Presacral neuroendocrine neoplasms (NENs) are rare entities that are found at the presacral space. We report our experience in the diagnosis, management, and outcomes of primary presacral NENs. Methods This was an institutional review board–approved retrospective review of medical records and surgical pathology specimens of patients with a diagnosis of NENs at Cedars-Sinai Medical Center between January 2000 and April 2016. Results Ten patients were identified. The median age at presentation was 38 years (range, 20–77 years), and 8 were women. One patient presented with carcinoid-like symptoms, 2 were diagnosed incidentally, and 7 presented with symptoms related to mass effect. The median size of the tumor was 7.0 cm (range, 3–12 cm). On pathologic review, 3 of 10 were low-grade and well-differentiated, 5 of 10 were intermediate-grade and well-differentiated, 2 of 10 were grade 3 and classified as high-grade and poorly differentiated neuroendocrine tumors. Seven cases were metastatic on presentation with lymph node, liver, lung, or skeletal metastasis. Seven of 8 cases were detectable using Octreoscan. Eight patients were treated with a somatostatin analog and 5 patients were treated surgically. Conclusions Presacral NENs are clinically similar to gastroenteropancreatic tumors. Octreoscan imaging and somatostatin analog therapies were frequently applied. Further biologic characterization of this rare subtype is needed.