Rodrigo Gobbo Garcia

Doppler mapping of direct carotid-cavernous fistulae (DCCF).

The aims of this study were to establish Doppler criteria for identifying direct carotid-cavernous fistulae (DCCF), as well as the level of agreement between results obtained by Doppler mapping vs. angiography. Doppler mapping and angiography were used to assess the direction of flow in the superior ophthalmic veins and the resistivity index in the internal carotid arteries of 30 patients with DCCF. Both methods independently demonstrated reverse flow in superior ophthalmic vein ipsilateral to the DCCF in 22 patients and normal flow in another four. The mean resistivity index for internal carotid arteries with ipsilateral DCCF was significantly reduced (p = 0.0001) compared with that for contralateral internal carotid arteries without DCCF. A resistivity index value of 0.495 offered a sensitivity and specificity of 86.6% in diagnosing ipsilateral DCCF. These findings suggest that a resistivity index < 0.495 in the ipsilateral internal carotid artery, with or without reverse flow in the superior ophthalmic vein, is associated with a reasonable probability of diagnosing DCCF.

Prostate cancer detection using multiparametric 3 – tesla MRI and fusion biopsy: preliminary results

ABSTRACT Objective: To evaluate the diagnostic efficacy of transrectal ultrasonography (US) biopsy with imaging fusion using multiparametric (mp) magnetic resonance imaging (MRI) in patients with suspicion of prostate cancer (PCa), with an emphasis on clinically significant tumors according to histological criteria. Materials and Methods: A total of 189 consecutive US/MRI fusion biopsies were performed obtaining systematic and guided samples of suspicious areas on mpMRI using a 3 Tesla magnet without endorectal coil. Clinical significance for prostate cancer was established based on Epstein criteria. Results: In our casuistic, the average Gleason score was 7 and the average PSA was 5.0ng/mL. Of the 189 patients that received US/MRI biopsies, 110 (58.2%) were positive for PCa. Of those cases, 88 (80%) were clinically significant, accounting for 46.6% of all patients. We divided the MRI findings into 5 Likert scales of probability of having clinically significant PCa. The positivity of US/MRI biopsy for clinically significant PCa was 0%, 17.6% 23.5%, 53.4% and 84.4% for Likert scores 1, 2, 3, 4 and 5, respectively. There was a statistically significant difference in terms of biopsy results between different levels of suspicion on mpMRI and also when biopsy results were divided into groups of clinically non-significant versus clinically significant between different levels of suspicion on mpMRI (p-value <0.05 in both analyzes). Conclusion: We found that there is a significant difference in cancer detection using US/MRI fusion biopsy between low-probability and intermediate/high probability Likert scores using mpMRI.

Minimally invasive treatment of hepatic adenoma in special cases

ABSTRACT Hepatocellular adenoma is a rare benign tumor that was increasingly diagnosed in the 1980s and 1990s. This increase has been attributed to the widespread use of oral hormonal contraceptives and the broader availability and advances of radiological tests. We report two cases of patients with large hepatic adenomas who were subjected to minimally invasive treatment using arterial embolization. One case underwent elective embolization due to the presence of multiple adenomas and recent bleeding in one of the nodules. The second case was a victim of blunt abdominal trauma with rupture of a hepatic adenoma and clinical signs of hemodynamic shock secondary to intra-abdominal hemorrhage, which required urgent treatment. The development of minimally invasive locoregional treatments, such as arterial embolization, introduced novel approaches for the treatment of individuals with hepatic adenoma. The mortality rate of emergency resection of ruptured hepatic adenomas varies from 5 to 10%, but this rate decreases to 1% when resection is elective. Arterial embolization of hepatic adenomas in the presence of bleeding is a subject of debate. This observation suggests a role for transarterial embolization in the treatment of ruptured and non-ruptured adenomas, which might reduce the indication for surgery in selected cases and decrease morbidity and mortality. Magnetic resonance imaging showed a reduction of the embolized lesions and significant avascular component 30 days after treatment in the two cases in this report. No novel lesions were observed, and a reduction in the embolized lesions was demonstrated upon radiological assessment at a 12-month follow-up examination.

Are Dynamic Contrast-Enhanced Images Necessary for Prostate Cancer Detection on Multiparametric Magnetic Resonance Imaging?

Micro‐Abstract The purpose of our study was to compare the results of magnetic resonance imaging with and without contrast for the detection of prostate cancer. A total of 118 patients were included in the present study, and clinically significant cancer was found in 48. The magnetic resonance imaging findings on both analyses had no statistically significant differences. The use of contrast provided no increased value for the detection of prostate cancer. Background: To compare the results of magnetic resonance imaging (MRI) with and without contrast‐enhanced sequences for the detection of clinically significant prostate cancer. The value of contrast in the MRI protocol for the detection of prostate tumors has been discussed in previous studies. Materials and Methods: We performed an institutional review board‐approved, retrospective study of patients who had undergone prostate MRI followed by fusion biopsy during a 16‐month period. The patients had undergone MRI on a 3‐Tesla scanner with a phased‐array coil using a routine multiparametric protocol: T2‐weighted, diffusion, and dynamic postcontrast enhancement sequences. The examination films were read independently by 2 readers in 2 sessions: first without contrast‐enhanced images and second with contrast‐enhanced images. The images were graded according to the suspicion of clinically significant prostate cancer (scale, 1‐5). The kappa coefficient was used to compare the readings with and without contrast. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for both readers were calculated using the biopsy findings as a reference standard. The level for statistical significance was set at P < .05. Results: A total of 118 patients were included, and clinically significant prostate cancer was found in 48 patients (40.7%). The MRI findings on both contrast‐enhanced and noncontrast‐enhanced images had no statistically significant differences for either reader (P > .05 for all levels of suspicion). The sensitivity ranged from 68.3% to 80.7%, specificity from 57.1% to 77.1%, positive predictive value from 29.9% to 38.8%, negative predictive value from 88.0% to 91.3%, and accuracy from 60.6% to 73.0%. Conclusion: Our results show that contrast‐enhanced sequences provide minimal or no increased value for the detection of clinically significant prostate cancer.

Applications for a hybrid operating room in thoracic surgery: from multidisciplinary procedures to ­­image-guided video-assisted thoracoscopic surgery

The concept of a hybrid operating room represents the union of a high-complexity surgical apparatus with state-of-the-art radiological tools (ultrasound, CT, fluoroscopy, or magnetic resonance imaging), in order to perform highly effective, minimally invasive procedures. Although the use of a hybrid operating room is well established in specialties such as neurosurgery and cardiovascular surgery, it has rarely been explored in thoracic surgery. Our objective was to discuss the possible applications of this technology in thoracic surgery, through the reporting of three cases.ABSTRACT The concept of a hybrid operating room represents the union of a high-complexity surgical apparatus with state-of-the-art radiological tools (ultrasound, CT, fluoroscopy, or magnetic resonance imaging), in order to perform highly effective, minimally invasive procedures. Although the use of a hybrid operating room is well established in specialties such as neurosurgery and cardiovascular surgery, it has rarely been explored in thoracic surgery. Our objective was to discuss the possible applications of this technology in thoracic surgery, through the reporting of three cases.

Cerebral air embolism during CT-guided lung biopsy

A patient with cirrhosis and hepatocellular carcinoma, on the waiting list for liver transplantation, presented with lung nodule during initial evaluation. A CT-guided core needle lung biopsy under general anaesthesia was performed. Pneumothorax (figure 1) and a large amount of gas within the left ventricle (figure 2) were identified during the procedure. …

Incremental diagnostic value of targeted biopsy using mpMRI-TRUS fusion versus 14-fragments prostatic biopsy: a prospective controlled study

ObjectivesTo compare the incremental diagnostic value of targeted biopsy using real-time multiparametric magnetic resonance imaging and transrectal ultrasound (mpMRI-TRUS) fusion to conventional 14-cores biopsy.Patients and MethodsUni-institutional, institutional review board (IRB) approved prospective blinded study comparing TRUS-guided random and targeted biopsy using mpMRI-TRUS fusion, in 100 consecutive men. We included men with clinical-laboratorial suspicious for prostate cancer and Likert score ≥ 3 mp-MRI. Patients previously diagnosed with prostate cancer were excluded. All patients were submitted to 14-cores TRUS-guided biopsy (mpMRI data operator-blinded), followed by targeted biopsy using mpMRI-TRUS fusion.ResultsThere was an overall increase in cancer detection rate, from 56% with random technique to 62% combining targeted biopsy using mpMRI-TRUS fusion; incremental diagnosis was even more relevant for clinically significant lesions (Gleason ≥ 7), diagnosing 10% more clinically significant lesions with fusion biopsy technique. Diagnosis upgrade occurred in 5 patients that would have negative results in random biopsies and had clinically significant tumours with the combined technique, and in 5 patients who had the diagnosis of significant tumours after fusion biopsy and clinically insignificant tumours in random biopsies(p=0.0010).ConclusionsTargeted biopsy using mpMRI-TRUS fusion has incremental diagnostic value in comparison to conventional random biopsy, better detecting clinically significant prostate cancers.Key Points• mpMRI-TRUS targeted biopsy increases overall cancer detection rate, but not statistically significant.• mpMRI-TRUS targeted biopsy actually improves the diagnosis of clinically significant PCa.• There was no evidence to acquire the mpMRI-TRUS fusion cores alone.

Image-guided percutaneous renal cryoablation: Five years experience, results and follow-up

OBJECTIVES To describe the experience of our institution in image-guided renal nodules percutaneous cryoablation, evaluating demographic and technical aspects as well as efficacy, safety and follow up. MATERIALS AND METHODS Retrospective study approved by our institutional review board. Seventy-one renal tumors evaluated in 60 patients treated with image guided percutaneous renal cryoablation from January 2009 to December 2015. No patient was excluded from study, even those who were lost on follow up. All the procedures were guided both by ultrasound and tomography. An argon and helium based cryoablation machine was used for all treatments. Hydrodissection was performed when the bowel or ureters were within 1 cm (iodinated contrast media in dextrose solution). Complications were assessed by the terminology criteria of the National Institutes of Health (NIH). Patients were monitored and evaluated by ultrasound, tomography, MRI and/or PET-CT. RESULTS In most procedures (91.9%) only one nodule was treated. Nodules had a median size of 1.6 cm. Most nodules (61,9%) were exophytic. Hydrodissection and retrograde warm pyeloperfusion were performed in most procedures. Among all variables evaluated in univariate analysis, nearness of nodule to collecting system and anterior/posterior location were significantly associated with PRCA complications. No other factor evaluated was significantly associated with complications. CONCLUSION PRCA is solid alternative to traditional surgical therapies for treatment of small renal tumors in wide subset of patients. Medium term evidence shows excellent long-term oncological results, similar to nephrectomy, with minimal risk of major complications.

Percutaneous Cholecystostomy and Hydrodissection in Radiofrequency Ablation of Liver Subcapsular Leiomyosarcoma Metastasis Adjacent to the Gallbladder: Protective Effect.

Uterine leiomyosarcoma is an uncommon pathology, predominantly found in aged population. Patients with metastatic disease have poor survival and therapy mainly consists of palliative systemic chemotherapy. However, more aggressive strategies such as radiofrequency ablation (RFA) may benefit patients with limited secondary disease. RFA is considered a simple and safe modality for treatment of hepatic lesions. The benefits related to RFA include low morbidity, short hospital stay and the possibility to repeat the procedure when necessary due to recurrences. However, minor and major complications related to mechanical and thermal damage may occur, especially in cases of tumors adjacent to extrahepatic organs and those at subcapsular position. This case report shows a successful RFA of two hepatic subcapsular leiomyosarcoma metastases neighbouring the gallbladder, without a safe cleavage plane from it. Combined hydrodissection, percutaneous cholecystostomy and continuous irrigation were performed as effective techniques to prevent thermal injury. Clinical and radiological follow up demonstrates no local complication.

Multiparametric magnetic resonance imaging findings of prostatic pure leiomyomas

ABSTRACT Objective: To describe the imaging findings of prostatic tumors nonadenocarcinoma on multiparametric magnetic resonance imaging. Methods: A total of 200 patients underwented multiparametric magnetic resonance imaging of the prostate for screening for prostate cancer, from August 2013 to September 2014, followed by biopsy with ultrasound/magnetic resonance imaging fusion. Results: We found three pathologic proved cases of prostatic pure leiomyomas (0.02%) in our series and described the multiparametric magnetic resonance imaging features of these prostatic leiomyomas. The imaging findings had similar features to lesions with moderate or high suspicion for significant cancer (Likert 4 or 5) when localized both in the transitional zone or in the peripheral zone of the gland. Conclusion: Pure prostatic leiomyomas had imaging findings on multiparametric magnetic resonance imaging that mimicked usual adenocarcinomas on this test. Radiologists, urologists and pathologists must be aware of this entity and its imaging features.