Ricardo García-Mónaco

Randomized controlled trial of irinotecan drug‐eluting beads with simultaneous FOLFOX and bevacizumab for patients with unresectable colorectal liver‐limited metastasis

Reports have demonstrated the superior activity of combining both irinotecan and oxaliplatin (FOLFOXIRI) therapy. An option for gaining similar benefits with less toxicity would be the administration of irinotecan through a hepatic artery approach. The aim of this study was to assess the response and adverse event rates for irinotecan drug‐eluting beads (DEBIRI) with folinic acid, 5‐fluorouracil, and oxaliplatin (FOLFOX) and bevacizumab as a first‐line treatment for unresectable colorectal liver metastasis.

Kaposiform Hemangioendothelioma with Kasabach-Merritt Phenomenon: Successful Treatment with Embolization and Vincristine in Two Newborns

Kaposiform hemangioendothelioma (KHE) is a rare vascular tumor and has a high mortality in newborns when associated with Kasabach-Merritt syndrome (KMS). In two newborns with KHE and severe KMS refractory to medical treatment, emergency embolization led to clinical improvement in the acute neonatal setting by reducing tumor volume, increasing the platelet count, and improving other clotting parameters. Systemic vincristine treatment was added for further tumor control. Both patients remained symptom-free at long-term follow-up.

Transarterial Treatment of Colorectal Cancer Liver Metastases with Irinotecan-Loaded Drug-Eluting Beads: Technical Recommendations

Transcatheter hepatic arterial administration of irinotecan-loaded drug-eluting beads (DEBIRI) is used to treat liver-only or liver-dominant metastatic disease from colorectal cancer (CRC). Eligibility for DEBIRI should be established in each individual patient by a multidisciplinary team based on comprehensive clinical, imaging, and laboratory assessment. Standardization of DEBIRI technique and protocols would be expected to lead to improved efficacy and safety. The present article provides a set of technical recommendations for the use of DEBIRI in the treatment of hepatic CRC metastases.

Usefulness of MRI in takotsubo cardiomyopathy: a review of the literature

Takotsubo cardiomyopathy (TC) is a disease that can be misinterpreted as a more serious acute coronary syndrome. Its clinical characteristics resemble those of a myocardial infarct, while its imaging characteristics are critical on correctly characterizing and diagnosing the disease. From angiography, where coronary anatomy is evaluated, to cardiac magnetic resonance (CMR), where morphology and tissue characterization is assessed, the array of imaging options is quite extent. In particular, CMR has achieved great improvements (stronger magnetic fields, better coils, etc.) in the last decade which in turn has made this imaging technology more attractive in the evaluation and diagnosis of TC. With its superior soft tissue resolution and dynamic imaging capabilities, CMR is currently, perhaps, the most useful imaging technique in TC as apical ballooning or medio-basal wall motion abnormalities (WMA), presence of wall edema and late gadolinium enhancement (LGE) characteristics are critical in the diagnosis and characterization of this pathology. In this review, CMRs role in TC will be evaluated in light of the current available evidence in medical literature, while also revising the clinical and physiopathologic characteristics of TC.

Esophageal cancer: pneumo-64-MDCT.

BackgroundPre-surgical characterization and staging of esophageal cancer with only one imaging method could be useful since gastric invasion determines the scope of resection and the kind of surgery to be performed. Our aim is to demonstrate the usefulness of Pneumo-64-MDCT (PnCT64) in the presurgical characterization of esophageal neoplasms in correlation with surgical findings.Materials and methodsA total of 50 patients with diagnosis of esophageal neoplasm were prospectively studied. A 14 French Foley catheter was used transorally in all patients. Air was instilled through the catheter to achieve esophageal distension. A 64-row MDCT scan was performed and the tumor was characterized according to scope, shape and anatomic location by using multiplanar 3D reconstructions and virtual endoscopy. Wall infiltration and presence of adenopathies were analyzed.ResultsAdequate gastroesophageal distension was achieved in all patients. In 44/50 patients, wall thickening was observed, and in 34/50 regional adenopathies were found. In 29/50 patients the lesion was found in the lower third and in the gastroesophageal junction. The surgical correlation for wall infiltration was 85.7%.ConclusionsPnCT64 proved to be useful and safe for identification of esophageal wall thickening and presurgical characterization. Optimal distension allowed definition of both upper and lower borders of the tumors located in the gastroesophageal junction, of utmost importance to determine the surgical approach.

Leg Ulcer as a Complication of a Posttraumatic Tibial Arteriovenous Fistula Treated by Endovascular Approach With Stent-Graft Placement

Endovascular treatment of posttraumatic arteriovenous fistulae (AVFs) in the lower extremities by means of covered stent-grafts is widely accepted, and many cases have been reported in the iliac-femoral region. However, few reports exist on the treatment of infrapopliteal AVFs, with or without a pseudoaneurysm, using this method. The authors present this case report dealing with a patient who had undergone a tibial and peroneal open fracture in his left limb 34 years ago. He developed a leg ulcer as a consequence of AVF between the tibialis posterior artery and vein, which resulted in venous insufficiency, which was treated by the endovascular approach with the placement of a stent-graft. Total healing was achieved over a period of 3 months. Angio-CT was performed, showing stent-graft patency 6 months after the endovascular procedure.

Pneumo-CT assessing response to neoadjuvant therapy in esophageal cancer: Imaging-pathological correlation

Pneumo-computed tomography (PnCT) is a technique primarily developed and used to study stenotic lesions of the esophagus, gastroesophageal junction and stomach for pre-surgical planning. It helps to define both upper and lower borders of neoplasms located in the aforementioned areas. It achieves maximum lumen distension with CO2 highlighting thickened areas of the esophageal wall, thus allowing an accurate quantification of their extents. Although there are other alternatives for distension (oral contrast agents, water and effervescent granules), they may be suboptimal. Patients with locally advanced esophageal cancer have a dismal prognosis despite surgical resection. Therefore, neoadjuvant treatment strategies using radiation therapy and chemotherapy were developed to improve survival. Neoadjuvant therapy improves esophageal tumor prognosis in a substantial proportion of patients, and the use of imaging techniques is mandatory to detect their response. PnCT combined with virtual endoscopy and multiplanar reconstruction enhances morphologic details in esophageal cancer, and thus would allow an improved assessment of response to neoadjuvant treatment. Therefore, more information could be provided to assess the efficacy of pre-surgical treatment. We describe the potential use of PnCT to assess the response to neoadjuvant therapy in esophageal cancer with an imaging pathologic correlation.

MDCT findings after hepatic chemoembolization with DC-beads: What the radiologist needs to know

Transcatheter arterial chemoembolization with drug-eluting beads (TACE-DC-beads) is a new local treatment for primary or metastatic liver tumors. Despite technical efforts to achieve highly selective embolization of the tumor-supplying vessels, small, or large insults to the non-tumorous parenchyma are inevitably induced by the embolic materials or procedure itself. Parenchymal changes following TACE-DC-beads include bile duct injuries (bile duct dilatation, periportal edema, and bilomas), obliteration of intrahepatic portal vein branches, hypodense ill-defined areas, and perilesional parenchymal enhancement. The radiologist must be familiar with the changes induced by this treatment in order to distinguish therapeutic effect and collateral findings from complications and residual or recurrent tumor.

Low rate of cardiovascular events in patients with acute myocarditis diagnosed by cardiovascular magnetic resonance

BACKGROUND Myocarditis is a relatively common inflammatory disease that affects the myocardium. Infectious disease accounts for most of the cases either because of a direct viral infection or post-viral immune-mediated reaction. Cardiovascular magnetic resonance (CMR) has become an established non-invasive diagnosis tool for acute myocarditis. A recent large single centre study with patients with biopsy-proven viral myocarditis undergoing CMR scans found a high rate of mortality. The aim of this study was to assess the rate of clinical events in our population of patients with diagnosed myocarditis by CMR scan. METHODS Patients who consulted to the emergency department with diagnosis of myocarditis by CMR were retrospectively included in the study from January 2008 to May 2012. A CMR protocol was used in all patients, and were followed up to assess the rate of the composite endpoint of all-cause death, congestive heart failure, sudden cardiac death, hospitalization for cardiac cause, recurrent myocarditis or need of radiofrequency ablation or implantable cardiac defibrillator (ICD). A descriptive statistical analysis was performed. RESULTS Thirty-two patients with myocarditis were included in the study. The mean age was 42.6±21.2 years and 81.2% were male. In a mean follow up of 30.4±17.8 months, the rate of the composite endpoint of all-cause death, congestive heart failure, sudden cardiac death, hospitalization for cardiac cause, recurrent myocarditis or need of radiofrequency ablation or ICD was 15.6% (n=5). Two patients had heart failure (one of them underwent heart transplant), one patient needed ICD because of ventricular tachycardia and two other patients were re-hospitalized, for recurrent chest pain and for recurrent myocarditis respectively. CONCLUSIONS In our series of acute myocarditis diagnosed by CMR we found a low rate of cardiovascular events without mortality. These findings might oppose data from recently published myocarditis trials.

Unexpected outcome after standard uterine embolization in obstetric hemorrhage

We have read with great interest the paper by Dr. Coulange et al. (1), who described two cases of uterine necrosis subsequent to embolization with resorbable material. Although the occurrence of necrosis in such cases seems unlikely, we believe that certain factors could be held responsible and are independent from the nature of the embolic agent. It has been demonstrated that the gelatin sponge preparation can have a direct effect on the final size of the particles used for embolization (2). For instance, if the ‘pumping’ technique is used, particles smaller than 500 m are capable of blocking the distal anastomotic blood flow. On the other hand, the ‘cutting’ technique produces a higher number of particles over 2,000 m, thus reducing the risk of distal anastomotic blockage and, therefore, of uterine necrosis. Other technical aspects to be considered rely on the embolization technique. Free flow embolization is mandatory to correctly target the embolic material, avoiding occlusion of uterine anastomoses or undesired distal embolization. If the embolization technique is made with high pressure, this would reroute to distal anastomotic channels, increasing the risk of unwanted occlusion. Lastly, we would like to emphasize the role of the not so well known lower uterine anastomotic system (3). This arterial net helps to maintain blood supply to the uterus once both uterine and ovarian arteries are occluded. For many years, the ovarian system and the artery of the round ligament were thought to be responsible for flow to the uterus if the uterine arteries were occluded. However, later studies showed that tangential compression of the uterine artery and of its lower anastomoses rendered the compensating flow through the upper pedicle impossible, leading to ischemia within six hours (4). The simultaneous occlusion of both uterine arteries and the vaginal anastomotic pedicle in the first case could have led to anastomotic insufficiency and subsequent necrosis. As to the second case, we believe that a series of already mentioned factors caused the undesired embolization of the right adnexa. We do not agree with the statement that the absence of a uterine-ovarian anastomotic network constituted a risk factor since, if it did not exist, retrograde embolization of the ovary through the uterine artery would be anatomically impossible. Finally, we would like to congratulate the authors, because the publication of infrequent cases of serious complications will no doubt contribute to the continuous improvement of endovascular treatment of postpartum hemorrhage.