Sung-Gwon Kang

Palliative treatment with self-expandable metallic stents in patients with advanced type III or IV hilar cholangiocarcinoma: a percutaneous versus endoscopic approach.

BACKGROUND AND OBJECTIVE Endoscopic or percutaneous biliary drainage with self-expandable metallic stents (SEMS) is widely used for the palliation of cholestasis in patients with advanced hilar cholangiocarcinoma. However, little is known about which is the better option in patients with advanced hilar cholangiocarcinoma. We compared the clinical outcomes of these 2 methods of biliary decompression in these patients. DESIGN AND SETTING Multicenter retrospective study. PATIENTS A total of 85 patients with newly diagnosed advanced hilar cholangiocarcinoma (Bismuth III or Bismuth IV) and who did not receive an operation, chemotherapy, or radiotherapy were retrospectively reviewed. Forty-four of the 85 received endoscopic SEMS and 41 received percutaneous SEMS. INTERVENTIONS Endoscopic SEMS or percutaneous SEMS. MAIN OUTCOME MEASUREMENTS AND RESULTS Baseline characteristics were similar in the 2 groups, but the rate of successful biliary decompression was significantly higher in the percutaneous SEMS group than in the endoscopic SEMS group (92.7% vs 77.3%, respectively, P= .049). Overall rates of procedure-related complications were similar for the 2 groups, but 1 death (from biliary sepsis) occurred in the endoscopic SEMS group. Median survival of patients in whom biliary drainage was successful initially, regardless of which procedure was performed, was much longer than that of patients who had failed biliary drainage (8.7 months vs 1.8 months, respectively, P< .001). Once successful biliary decompression had been achieved, median survival and stent patency duration were similar in the 2 study groups. LIMITATION Retrospective study. CONCLUSIONS Percutaneous SEMS may be chosen for initial biliary drainage in patients with advanced type III or IV hilar cholangiocarcinoma, given higher initial success rate and low level of procedure-related cholangitis.

Single-session Combined Therapy with Chemoembolization and Radiofrequency Ablation in Hepatocellular Carcinoma Less than or Equal to 5 cm: A Preliminary Study

PURPOSE To evaluate the efficacy and safety of a single-session combined chemoembolization and radiofrequency (RF) ablation for hepatocellular carcinomas (HCCs) less than or equal to 5 cm. MATERIALS AND METHODS Between June 1, 2004, and January 1, 2006, 50 patients (41 men, nine women; age range, 35-77 years; mean age, 61.5 years) with 57 HCCs (1.5-4.5 cm; mean, 2.4 cm) underwent single-session combined therapy. Chemoembolization was performed by using a doxorubicin hydrochloride/iodized oil emulsion with or without gelatin sponge particles. Immediately following chemoembolization, RF ablation was performed under fluoroscopy or ultrasonographic guidance. Initial tumor response and local tumor progression were determined with follow-up computed tomography or magnetic resonance imaging. The recurrence-free and overall survival rates as well as procedure-related complications were evaluated. RESULTS At 1-month follow up, complete necrosis was achieved in all index tumors; however, nonindex intrahepatic recurrences were found in two patients (complete response in 48 patients and progressive disease in two patients). The estimated 1- and 3-year local tumor progression rates during the follow-up period (range, 13.1-51.6 months; mean, 29.0 months) were 1.8% and 9.4%, respectively. The 1- and 3-year recurrence-free and overall survival rates were 64.6% and 30.5% and 100% and 79.7%, respectively. Three of the 50 patients (6%) had major complications, including segmental hepatic infarction (n = 2) and hepatic arterial bleeding (n = 1). CONCLUSIONS Single-session combined therapy is an effective and safe treatment for HCCs less than or equal to 5 cm.

Bronchial Artery Embolization to Control Hemoptysis: Comparison of N-Butyl-2-Cyanoacrylate and Polyvinyl Alcohol Particles

PURPOSE To retrospectively compare safety and effectiveness of embolic agents polyvinyl alcohol (PVA) particles versus n-butyl-2-cyanoacrylate (NBCA) for bronchial artery embolization (BAE) for control of hemoptysis. MATERIALS AND METHODS Institutional review board approved this retrospective study; informed consent was waived. From January 2005 to December 2008, 406 patients (242 men, 164 women; age range, 6-92 years) with major hemoptysis underwent BAE by using PVA particles (n = 293) or NBCA (n = 113). Technical and clinical success, complications, hemoptysis-free survival rates, and causes of recurrent hemoptysis were compared between PVA and NBCA groups. The differences in hemoptysis-free survival rates were assessed between subgroups stratified to underlying diseases. The predictive factor for recurrent hemoptysis was identified with Cox proportional hazard regression model. RESULTS Technical success was achieved in 93.9% (275 of 293) and 96.5% (109 of 113) of patients for PVA and NBCA, respectively (P = .463); clinical success was achieved in 92.2% (270 of 293) and 96.5% (109 of 113) of patients for PVA and NBCA, respectively (P = .180). Overall and major complication rates were not statistically different (overall complication rates: 34.1% for PVA, 31.0% for NBCA; P = .56; major complication rates: 0.3% for PVA, 0% for NBCA; P > .999). The 1-, 3-, and 5-year hemoptysis-free survival rates were, respectively, 77%, 68%, and 66% for PVA and 88%, 85%, and 83% for NBCA (P = .01). Recanalization of previously embolized vessels was more frequent in PVA group (21.5%) than in NBCA group (1.8%; P < .001). NBCA group showed hemoptysis-free survival rates superior to PVA group in patients with bronchiectasis (P = .016). PVA (P = .050) and aspergilloma (P < .001) were predictive factors for recurrent hemoptysis. CONCLUSION BAE with NBCA provided higher hemoptysis-free survival rates compared with PVA particles without increasing complication rates. This improvement was evident in patients with bronchiectasis and was caused by more durable embolic effect than PVA particles. SUPPLEMENTAL MATERIAL http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.13130046/-/DC1.

Lacrimal Canalicular Obstructions: Safety and Effectiveness of Balloon Dilation☆

PURPOSE Balloon dilation of the lacrimal canaliculi has been considered contraindicated because of possible damage to the canaliculi. The purpose of this study was to assess the safety and effectiveness of balloon dilation in treatment of obstruction of the lacrimal canaliculus. MATERIALS AND METHODS Fluoroscopically guided balloon dilation was performed in 26 eyes of 21 consecutive patients with epiphora due to lacrimal canalicular obstruction confirmed at dacryocystography. Nine of 26 eyes had complete obstruction and 17 eyes had incomplete obstruction. RESULTS Technical failure occurred in one eye. Only one acute complication (punctal slitting) and no late complications occurred. At 7 days after balloon dilation, 14 of 17 eyes (82%) with incomplete obstruction and five of nine eyes (56%) with complete obstruction showed complete or partial resolution of epiphora with patency of the lacrimal drainage system. At 6-month follow-up, that improvement was maintained in seven of 17 eyes (41%) with incomplete obstruction and three of nine eyes (33%) with complete obstruction. CONCLUSIONS Although the 6-month recurrence rate is rather high, balloon dilation seems to be safe and valuable as an initial therapy for patients with obstruction of the lacrimal canaliculus.

Failed Pelvic Arterial Embolization for Postpartum Hemorrhage: Clinical Outcomes and Predictive Factors

PURPOSE To evaluate clinical outcomes of failed pelvic arterial embolization (PAE) and determine predictive factors associated with this failure in the treatment of postpartum hemorrhage (PPH). MATERIALS AND METHODS This retrospective study included all consecutive patients who underwent PAE for life-threatening PPH between March 2004 and January 2011 at a tertiary-care center. Medical records and imaging studies were reviewed to identify cases of failed PAE and their clinical outcomes. Multiple parameters were compared between the failed and successful PAE groups, and multivariate analysis was performed to determine the predictive factors associated with failed PAE. RESULTS PAE was performed in 257 patients (mean age, 32 y; range, 20-40 y). A total of 24 cases of PAE involved a failure to achieve hemostasis (9.3%). Patients in the failed PAE group experienced more major complications than those in the successful PAE group (37.5% [nine of 24] vs 9.4% [22 of 233]). Factors more frequently found in failed PAE included hemodynamic instability, hemoglobin level lower than 8g/dL, disseminated intravascular coagulation (DIC), and extravasation detected on angiography. After multivariate analysis, DIC emerged as the only significant predictive factor (odds ratio, 6.569; 95% confidence interval, 1.602-26.932; P = .009). CONCLUSIONS PAE is an effective treatment for medically intractable PPH. However, PAE failed in a high percentage of patients and was commonly associated with major complications. DIC was the only significant predictor of failed PAE.

Epidermal growth factor 61 A/G polymorphism and uterine cervical cancer

Cervical cancer, the second most common malignancy in women worldwide, is almost invariably associated with infection by human papillomavirus (HPV). However, although many women are infected with high-risk types of HPV, only a subset of infected women will ever develop cervical cancer. Therefore, host genetic factor may play a role in cervical carcinogenesis. Alterations in epidermal growth factor receptor (EGFR) are common events in cervical cancer. Therefore, we hypothesized that a functional polymorphism in the 5′ untranslated region of the epidermal growth factor (EGF) gene, a natural ligand of the EGFR, may play a role in the cervical carcinogenesis and tumor invasiveness. We assessed the possible association between EGF +61 A/G polymorphism and cervical cancer risk in a hospital-based case–control study among 337 Korean women (168 cases, 169 age-matched controls). The frequencies of EGF +61 allele and genotype were not different between cases and controls. We observed increasing trend of lymph node metastasis from A/A homozygous genotype toward G/G homozygous genotype. We did not find any evidence that EGF +61 A/G polymorphism was associated with individual susceptibility of cervical cancer. However, although it was not statistically significant, the increasing trend of lymph node metastasis according to EGF genotype suggests the possibility that individual variance of EGF expression may be associated with cervical cancer invasiveness. We also confirmed that there exists striking ethnic heterogeneity of EGF genotype between Caucasian and East Asian population

Negative Regulation of Gonadotropin‐Releasing Hormone and Gonadotropin‐Releasing Hormone Receptor Gene Expression by a Gonadotropin‐Releasing Hormone Agonist in the Rat Hypothalamus

There exists evidence for the presence of ultrashort loop feedback circuits of gonadotropin‐releasing hormone (GnRH) secretion in the hypothalamus. It is, however, uncertain whether a similar mechanism is involved in the regulation of GnRH gene expression in vivo. Furthermore, little is known about the regulation of GnRH receptor (GnRHR) expression in the brain. In the present study, we examined the regulation of GnRH and its receptor gene expression by GnRH in vivo. A GnRH agonist, [D‐Ala6, des‐Gly10]GnRH‐ethylamide (des‐Gly GnRH), was administered by intracerebroventricular (i.c.v.) injection via the lateral ventricle of ovariectomized and estradiol (OVX+E)‐treated rats. The amounts of GnRH and GnRHR mRNA were measured in the preoptic area (POA) and posterior mediobasal hypothalamus (pMBH) micropunch samples from individual rat brain slices by respective competitive reverse transcription‐polymerase chain reactions. The i.c.v. administration of des‐Gly GnRH significantly decreased GnRH and GnRHR mRNA expression in a dose‐and time‐related manner: des‐Gly GnRH (6 ng) suppressed GnRH and GnRHR mRNA expression within 2 h, and the suppression was maintained without significant variation until 8 h after treatment. Treatment with Antide, [N‐Ac‐ d‐Nal(2)1, pCl‐ d‐Phe2, d‐Pal(3)3, Lys(Nic)5, d‐Lys(Nic)6, Lys(iPR)8, d‐Ala10]GnRH (10 ng), a potent GnRH antagonist, did not alter GnRH mRNA expression, but prevented des‐Gly GnRH‐induced suppression of GnRH mRNA expression. Antide alone decreased GnRHR mRNA expression, but failed to alter agonist‐induced suppression of GnRHR mRNA expression. These results demonstrate the existence of an ultrashort loop feedback mechanism for GnRH gene expression in the POA, along with homologous down‐regulation of GnRHR mRNA expression in the pMBH.

Noradrenergic Neurotoxin Suppresses Gonadotropin‐Releasing Hormone (GnRH) and GnRH Receptor Gene Expression in Ovariectomized and Steroid‐Treated Rats

The present study was designed to investigate whether noradrenergic neurotransmission regulates the gene expression of gonadotropin‐releasing hormone (GnRH) in the preoptic area and GnRH receptor in the pituitary. To this end, N‐(2‐chloroethyl)‐N‐ethyl‐2‐bromobenzylamine (DSP4, 50 mg/kg), an intraperitoneal (i.p.) injection of selective noradrenergic neurotoxin, was administered 1 h before progesterone (1 mg) treatment in ovariectomized and estradiol‐treated prepubertal rats. Treatment with DSP4 effectively blocked the progesterone‐induced increase in hypothalamic noradrenaline content, but not dopamine content, indicating that DSP4 selectively inhibits noradrenergic neurotransmission. DSP4 significantly blocked progesterone‐induced increase in serum luteinizing hormone (LH) concentrations as well as GnRH release from hypothalamic fragments incubated in vitro. DSP4 concomitantly down‐regulated GnRH mRNA levels in the preoptic area, as determined by competitive reverse transcription‐polymerase chain reaction. DSP4 also clearly down‐regulated progesterone‐induced GnRH receptor mRNA levels in the pituitary, whereas it failed to alter LHβ mRNA levels. In summary, blockade of noradrenergic neurotransmission with DSP4 resulted in profound reductions of hypothalamic GnRH and pituitary GnRH receptor gene expression.

Palliative treatment of unresectable hepatocellular carcinoma with obstructive jaundice using biliary drainage with subsequent transarterial chemoembolization.

BACKGROUND Nonsurgical biliary drainage is considered as a priority for obstructive jaundice associated with unresectable hepatocellular carcinoma (HCC). Successful drainage allows the patient to receive antitumor therapy, such as transarterial chemoembolization (TACE). However, only limited data are available on clinical outcomes in patients who treated biliary drainage with subsequent TACE. OBJECTIVE This study evaluated the clinical outcome of biliary drainage with subsequent TACE in unresectable HCC patients with obstructive jaundice. DESIGN This was a retrospective study. SETTING/SUBJECTS A total of 60 patients received endoscopic biliary drainage (ERBD) or percutaneous transhepatic biliary drainage (PTBD) in two tertiary care referral centers. MEASUREMENTS Successful drainage and survival were measured. RESULTS Successful drainage was achieved in 39 (65%) patients. The median survival of 39 patients in whom successful drainage was achieved, regardless of which procedure was performed, was much longer than that of 21 patients without successful drainage (147 days versus 38 days, respectively, P<.001). In particular, the median survival was longer in 17 patients who underwent TACE after achieving successful drainage than in 22 patients who were treated conservatively after achieving successful drainage (410 days versus 77 days, respectively, P<.001). Multivariable analysis in 39 patients in the successful drainage group showed that TACE (hazard ratio 0.15; 95% confidence interval 0.05-0.45, P=.001) was an independent predictive factor of a favorable outcome. CONCLUSIONS Effective palliation by successful biliary drainage with subsequent TACE might prolong the survival in patients with obstructive jaundice caused by unresectable HCC.

Gastrointestinal Stent Update

The use of self-expanding metallic stents in the upper gastrointestinal tract, placed under radiologic imaging or endoscopic guidance, is the current treatment of choice for the palliation of malignant gastrointestinal outlet obstructions. Advances in metallic stent design and delivery systems have progressed to the stage where this treatment is now considered a minimally invasive therapy. Metallic stent placement will broaden further into the field of nonsurgical therapy for the gastrointestinal tract. To date, metallic stents placed in the esophagus, gastric outlet, colorectum, and bile ducts are not intended to be curative, but rather to provide a palliative treatment for obstructions. The evolution of metallic stent technology will render such procedures not only palliative but also therapeutic, by enabling local drug delivery, and the use of biodegradable materials will reduce procedure-related complications.