Theodore Petsas

CT angiography with three-dimensional techniques for the early diagnosis of intracranial aneurysms. Comparison with intra-arterial DSA and the surgical findings

INTRODUCTION Cerebral CT angiography (CTA) is an established method applied to both the detection and treatment planning of intracranial aneurysms. The aim of our study was to compare CTA and digital subtraction angiography (DSA) findings with the surgical results mainly in patients with acute SAH and to evaluate the clinical usefulness of CTA. MATERIALS AND METHODS During the last 2 years, 82 consecutive patients were admitted under clinical symptoms and signs suggestive of harboring an intracranial aneurysm. CT angiography performed immediately afterwards the plain CT, while DSA was performed within the first 48 h of admission. All aneurysms detected were confirmed during surgery or endovascular embolization. Repeat DSA was performed in all patients having both the initial CTA and the DSA 15 days after the onset of symptoms negative. CT angiograms and conventional angiographies were studied by a consensus of two radiologists for each technique, who performed aneurysm detection, morphological features characterization and evaluation of the technique. RESULTS Surgical or/and endovascular treatment was performed in 45 patients and 53 aneurysms were confirmed. Using 3D-CT angiography, we detected 47 aneurysms in 42 patients. Conventional angiography depicted 43 aneurysms in 39 patients. The sensitivity of CTA for the detection of all aneurysms versus surgery was 88.7%, the specificity 100%, the positive predictive value (PPV) 100%, the negative predictive value (NPV) 80.7% and the accuracy 92.3%. Accordingly, the sensitivity of DSA was 87.8%, the specificity 98%, the PPV 97.7%, the NPV 89.1% and the accuracy 92.9%. Considering aneurysms > or =3 mm, CTA showed a sensitivity ranging from 93.3 to 100%, equal to that of DSA. CONCLUSION Cerebral CT angiography has an equal sensitivity to DSA in the detection of intracranial aneurysms >3 mm. It has also 100% detection rate in AcoA and MCA bifurcation aneurysms, while some locations, like posterior communicating artery aneurysms, remain problematic. The delineating features of each aneurysm are better depicted with CTA due to 3D visualization. The use of digital subtraction angiography as a diagnostic tool can be limited in equivocal cases.

Osteoid Osteoma: Diagnosis and Treatment

Treatment of small but painful osteoid osteomas was traditionally based on either prolonged medication or resection. In the era of rapidly evolving minimally invasive techniques, reluctance has been posed against surgical interventions mostly due to their relatively high rates of recurrence, complications, or persistent pain. Nonetheless, incomplete pain control and intolerance to anti-inflammatory drugs unfavorably affect prognosis. The objective of this article is to explore the nature and clinical presentation of osteoid osteomas, discuss their imaging and histological features, review available data regarding surgical and percutaneous methods for addressing these lesions and comment on their feasibility, safety, and efficacy.

Ureteral stents: new ideas, new designs:

Ureteral stents represent a minimally invasive alternative to preserve urinary drainage whenever ureteral patency is deteriorated or is under a significant risk to be occluded due to extrinsic or intrinsic etiologies. The ideal stent that would combine perfect long-term efficacy with no stent-related morbidity is still lacking and stent usage is associated with several adverse effects that limit its value as a tool for long-term urinary drainage. Several new ideas on stent design, composition material and stent coating currently under evaluation, foreseen to eliminate the aforementioned drawbacks of ureteral stent usage. In this article we review the currently applied novel ideas and new designs of ureteral stents. Moreover, we evaluate potential future prospects of ureteral stent development adopted mostly by the pioneering cardiovascular stent industry, focusing, however, on the differences between ureteral and endothelial tissue.

Percutaneous minimally invasive management of iatrogenic ureteral injuries.

PURPOSE To present experience with the percutaneous management of iatrogenic ureteral injuries. PATIENTS AND METHODS Eighteen women and six men with a mean age of 59.3 years (range 33-80 years) received a diagnosis of ureteral injury sustained during gynecologic, urologic, and general surgical procedures. In a total of 25 injured ureters, 12 had interruption of continuity of their lumen, 10 were associated with contrast extravasation, and 3 were related to both. A standard percutaneous nephrostomy tract was established on the side of the afflicted kidney. Combined use of hydrophilic guidewires and balloon dilations were performed to achieve antegrade recanalization of the ureteral lesion. Then, a ureteral stent was inserted to assure patency. RESULTS Average stricture length was 1.21 (range 0.5-1.9 cm). Success of the aforementioned technique was possible in 18 ureters. Successful management in one session took place in 14 ureters. Average hospitalization time was 1.8 days (range 0-5 d). The follow-up period ranged between 12 and 18 months, with mean follow-up time of 12.9 months. Ureteral patency was evident at 1 week follow-up in six patients with obstructed ureters. In the remaining patients, balloon dilation of the stricture was repeated, and another stent was placed. Extravasation of contrast was observed in two patients with extravasating ureters in the same period. Nephrostomy tubes were removed after a mean indwelling period of 5.9 weeks (range 1-12 wks). Two patients treated by the described method died during their hospitalization in the intensive care unit because of sepsis from peritonitis that was related to colon injury and multiple concomitant injuries. Major complications were not observed in the remaining 22 patients during the follow-up period. CONCLUSION The minimally invasive management of ureteral injuries is a safe and efficient method for both ureteral obstruction and/or laceration in a wide range of iatrogenic ureteral injuries.

Potential Role of Bcl-2 and Bax mRNA and Protein Expression in Chronic Hepatitis Type B and C: A Clinicopathologic Study

Bcl-2 oncoprotein regulates programmed cell death by providing a survival advantage to rapidly proliferating cells, and bax protein promotes apoptosis by enchanting cell susceptibility to apoptotic stimuli. In this study, we assessed the expression of bcl-2 and bax in liver biopsies from patients with chronic hepatitis (CH) Type B (HBV) and C (HCV). The study comprised 65 liver biopsies from 65 patients with HBV (n = 37) and HCV (n = 28) and 10 normal liver biopsies as controls. The HAI score ranged from 3/18–13/18, and the fibrosis Stage, from 1–6 (7 HBV/10 HCV). Pathologic examination included the following: (1) immunohistochemical stains in paraffin sections for bcl-2 and bax protein expression, (2) Western blot analysis (bcl-2 and bax protein levels evaluation), (3) ISH (detection of bcl-2 and bax mRNA), and (4) ISH (TUNEL-ABI [apoptotic body index]). In CH cases, both bcl-2 and bax protein and mRNA were detected in portal and intralobular lymphocytes and in cholangiolar epithelial cells in interface areas and fibrous bands. Bax protein and mRNA was expressed within hepatocytes and epithelial cells of interlobular ducts in portal tracts. Bcl-2 mRNA was present in periportal hepatocytes only in cases with Stage 5–6 fibrosis. Western blot analysis showed a decreased bcl-2 and an increased bax expression toward advanced fibrotic stages. In CH cases, ABI was reverse correlated with the percentage of bcl-2 expression and was correlated directly with the percentage of bax expression (P < .001). The results of this study suggest that in cases of chronic HBV or HCV infection, bax may be involved in the hepatocyte cycle regulation during infection, whereas its expression in intraportal bile duct epithelium implies that this protein enhances susceptibility of these particular cells to apoptosis. The increased bax expression and ABI in fibrosis Stages 1–5, imply that they are responsible for hepatocytes depletion through apoptosis, during progress of liver fibrosis and fibrous tissue accumulation, until cirrhosis is established. Bcl-2 mRNA expression in periportal hepatocytes only in Stages 5 and 6 suggests that this oncogene is involved in the late stages of progressive liver fibrosis and failure and furthermore that periportal hepatocytes are resistant to apoptosis. Bcl-2 expression, in cholangioles of interface area, suggests that this oncoprotein may be involved in growth regulation of these epithelial cells. Further research is warranted to specify the exact role of apoptosis and apoptotic genes involved in liver fibrosis process in cases of chronic HBV and HCV infection. This may lead to new strategies in the management of human liver disease to prevent the progression to chronic liver failure.

EGFR, HER-2 and COX-2 levels in colorectal cancer

Aims:  Receptor tyrosine kinases epidermal growth factor receptor (EGFR) and HER‐2 and cyclooxygenase‐2 (COX‐2) are promising molecular targets for cancer therapy and/or prevention. The aim was to evaluate EGFR, HER‐2 and COX‐2 mRNA and protein expression in colorectal cancer patients.

The potential role of TGFbeta1, TGFbeta2 and TGFbeta3 protein expression in colorectal carcinomas. Correlation with classic histopathologic factors and patient survival.

Purpose:This study investigates the expression of tumor growth factors TGFβ1, TGFβ2 and TGFβ3 in tissue material from patients with colorectal carcinoma and evaluates their correlation with known prognostic markers and patient survival.Patients and Methods:The study included 124 patients with colorectal carcinoma. According to the TNM classification of malignant tumors, 26 tumors were identified as being stage I, 30 stage II, 48 stage III, and 20 stage IV, whereas 106 tumors were low-grade and 18 high-grade malignancies. On paraffin sections, the streptavidin-biotin technique using antibodies against TGFβ1, TGFβ2 and TGFβ3 was applied. Morphological and immunohistochemical results were correlated with clinicopathologic parameters.Results:TGFβ1 protein was expressed in 88 out of 124 (71%) carcinomas, whereas TGFβ2 and TGFβ3 proteins were detected in all tumors examined. Normal colonic mucosal epithelial cells expressed TGFβ2 (significantly less as compared to neoplastic cells; p < 0.01) and TGFβ3 (p > 0.05 compared to neoplastic cells), but not TGFβ1. Statistical analysis revealed a higher expression of TGFβ1 in low-grade carcinomas (p = 0.009) and a higher presence of TGFβ2 in advanced tumors (p = 0.008). TGFβ1 expression was related with increased disease-free and overall survival (p < 0.05 each). The presence of TGFβ2 was correlated with worse prognosis (p < 0.05). Cox analysis revealed that besides tumor grade and stage, TGFβ1 expression constituted an independent prognostic factor.Conclusion:This study shows that in adenocarcinomas of the colon, there is a differential expression of TGFβ1, TGFβ2 and TGF3. TGFβ1 may be implicated in the pathogenesis of these tumors, since it is expressed only in neoplastic but not in normal cells. TGFβ1 is related with an increased disease-free and overall survival and constitutes an independent prognostic factor. In advanced stages, TGFβ2 seems to be involved in tumor progression and is related with worse prognosis.Ziel:Diese Studie untersuchte die Expression der Tumorwachstumsfaktoren TGFβ1, TGFβ2 and TGFβ3 in Gewebeproben von Patienten mit kolorektalen Karzinomen und prüfte ihre Korrelation mit bekannten prognostischen Markern und mit dem Überleben der Patienten.Patienten und Methodik:Die Studie umfasste 124 Patienten mit kolorektalen Karzinomen. Nach der TNM-Klassifikation wurden 26 Tumoren als Stadium I, 30 als Stadium II, 48 als Stadium III und 20 als Stadium IV eingeordnet, während 106 Tumoren Low-Grade- und 18 High-Grade-Malignome waren. Paraffinschnittpräparate wurden nach der Streptavidin-Biotin-Methode mit Antikörpern gegen TGFβ1, TGFβ2 und TGFβ3 behandelt. Die morphologischen und immunhistochemischen Befunde wurden mit klinisch-pathologischen Parametern korreliert.Ergebnisse:TGFβ1 wurde in 88 von 124 (71%) Karzinomen exprimiert, während TGFβ2 und TGFβ3 in allen untersuchten Tumoren gefunden wurden. Normale Epithelzellen der Dickdarmschleimhaut exprimierten TGFβ2 (signifikant weniger verglichen mit neoplastischen Zellen; p < 0,01) und TGFβ3 (p > 0,05 verglichen mit neoplastischen Zellen), aber kein TGFβ1. Die statistische Analyse ergab stärkere TGFβ1-Expression in Low-Grade-Karzinomen (p = 0,009) und eine verstärkte Präsenz von TGF2 in fortgeschrittenen Tumoren (p = 0,008). Die TGFβ1-Expression korrelierte mit verlängertem krankheitsfreien und Gesamtüberleben (jeweils p < 0,05). Das Vorliegen von TGFβ2 korrelierte mit schlechterer Prognose (p < 0,05). Die Cox-Analyse ergab, dass neben Tumorgrad und -stadium die TGFβ1-Expression einen unabhängigen prognostischen Faktor darstellte.Schlussfolgerung:Diese Studie zeigt für Adenokarzinome des Kolons und Rektums Unterschiede in der Expression von TGFβ1, TGFβ2 und TGFβ3. TGFβ1 könnte in der Pathogenese dieser Tumoren eine Rolle spielen, da es nur in neoplastischen, nicht aber in normalen Zellen exprimiert wird. TGFβ1 geht mit verlängertem krankheitsfreien und Gesamtüberleben einher und ist ein unabhängiger prognostischer Faktor. In fortgeschrittenen Stadien scheint TGFβ2 für die Tumorprogression relevant zu sein und ist mit einer schlechteren Prognose verbunden.

Potential role of hepatic progenitor cells expression in cases of chronic hepatitis C and their relation to response to therapy: a clinicopathologic study

Abstract: Background: This study investigates the correlation of hepatic progenitor cells (HPC) expression with treatment response in patients with chronic hepatitis C.

fibrin glue for sealing the needle track in fine-needle percutaneous lung biopsy using a coaxial system: Part II—clinical study

PurposeFollowing percutaneous lung biopsy (PLB), we used fibrin glue as a sealant in 26 patients for the purpose of decreasing the incidence of pneumothorax.MethodsAll 26 patients (group A) had chronic obstructive pulmonary disease (COPD). The results for group A were compared with a control group of 32 patients (group B), also with COPD and in whom fibrin glue was not used. All biopsies were conducted under computed tomography (CT) using a coaxial needle system consisting of 19-gauge and 22-gauge needles.ResultsPneumothorax developed in five patients (19.2%) in group A and in one instance, drainage was required (3.8%). In group B, pneumothorax developed in 13 patients (40.6%) and in six instances (18.8%) drainage was required. Comparing the use of chest-tube drainage in the two groups, a statistical significance was observed, p < 0.025. No adverse reactions related to the fibrin glue were observed.ConclusionOur results indicate that fibrin glue is a safe sealing material for lung PLB and serves to decrease the incidence and, in particular, the severity of pneumothorax, especially in high-risk patients.

A phase II study of capecitabine plus oxaliplatin (XELOX): a new first-line option in metastatic colorectal cancer.

AbstractBackground: Capecitabine and oxaliplatin are both effective and well-tolerated monotherapies for the treatment of advanced colorectal cancer (CRC). Oxaliplatin has also been shown to be very effective when combined with 5-FU/LV in the first-line setting. Aim of the Study: Assess the efficacy and safety of capecitabine plus oxaliplatin (XELOX) in patients with previously untreated advanced CRC. Methods: Fifty-three patients with measurable disease received capecitabine 1,000 mg/m2 twice daily on d 1–14 and oxaliplatin 130 mg/m2 on d 1, every 3 wk. Of these, 52 were evaluable for safety and 49 for antitumor response. Results: There was a low rate of grade 1/2 adverse events; grade 3/4 events included leukopenia (10%), neutropenia (6%), thrombocytopenia (2%), nausea/vomiting (4%), and diarrhea (4%). The overall response rate was 39% (95% CI, 25–54%) and median time to disease progression was 7.8 mo. Conclusions: XELOX is an active and well-tolerated first-line treatment for advanced CRC. Randomized phase III studies are ongoing to compare XELOX with FOLFOX in view of the comparable efficacy and safety but superior convenience of XELOX therapy.