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Background Liver transplant hepatic venous anastomoses are usually created using “bicaval” or “piggyback” techniques, which may result in unfavorable angulation between the inferior vena cava and hepatic veins, and makes hepatic vein catheterization and tissue sampling during transjugular liver biopsy (TLB) technically challenging. Purpose To compare the technical successes and complications of TLBs for recipients of liver transplants with bicaval and piggyback hepatic vein anastomoses. Material and Methods Information on type of hepatic vein surgical anastomosis was available for 190 adult patients in whom 306 consecutive TLBs were performed during 2009–2017: 158 with bicaval and 148 with piggyback anastomoses. The primary outcome of procedural success was defined as obtaining a tissue sample sufficient to make a pathologic diagnosis. Results A technical success rate of 97% with adequate liver tissue for diagnosis was similar between the anastomotic groups ( P = 0.50). TLB was unsuccessful in 3% of patients with piggyback anastomoses due to unfavorable hepatic venous anatomy whereas biopsy was successful in all patients with bicaval anastomoses ( P = 0.02). Fluoroscopy times were not significantly different (12.1 vs. 13.9 min, P = 0.08). Rates of major complication were similar between the two groups (3% vs. 3%, P > 0.99). Conclusion TLB is safe and effective for liver transplant patients regardless of the type of hepatic vein anastomosis. While failure to catheterize or advance the stiffened biopsy cannula into the hepatic vein is more likely to occur in patients with piggyback anastomoses, this is a rare occurrence.

Author(s): Mossa-Basha, Mahmud; Meltzer, Carolyn C; Kim, Danny C; Tuite, Michael J; Kolli, K Pallav; Tan, Bien Soo

Purpose To evaluate efficacy and safety of transjugular liver biopsy (TJLB) via the left hepatic vein in patients with left lobe–only liver transplants (LLOTs). Materials and Methods Retrospective review revealed 43 TJLBs performed in 26 patients with LLOTs (mean age 51.3 y; range, 18–73 y) between January 2009 and June 2016 at a single institution. A comparison group of 44 randomly selected TJLBs performed in 37 orthotopic whole liver transplant (OWLT) recipients (mean age 57.6 y; range, 35–74 y) during the same time period was evaluated. Patient demographics, type and age of transplant, technical success, adequacy of samples, number of portal tracts obtained, pathologic diagnosis, and complication rate were reviewed. Results Technical success was achieved in 98% (42/43) of LLOT procedures. TJLB failed in 1 patient with LLOT, in whom no patent hepatic veins were identified. Technical success was achieved in 100% (44/44) in the OWLT group. Mean (SD) number of needle passes was 4.12 (1.25) in the LLOT group vs 3.95 (1.28) in the OWLT group (P = .54). Mean (SD) specimen length was 1.16 (0.75) cm in the LLOT group vs 1.19 (0.58) cm in the OWLT group (P = .78). Mean (SD) number of portal tracts obtained in the LLOT group was 10.7 (5.26) vs 12.3 (4.68) in the OWLT group (P = .17). No major complications were observed in either group. Conclusions TJLB in adult patients with LLOTs appears safe and feasible, with favorable rates of technical success and adequacy of sampling.

Complications of portal hypertension, including ascites, gastrointestinal bleeding, hepatic hydrothorax, and hepatic encephalopathy, are associated with significant morbidity and mortality. Despite few high-quality randomized controlled trials to guide therapeutic decisions, transjugular intrahepatic portosystemic shunt (TIPS) creation has emerged as a crucial therapeutic option to treat complications of portal hypertension. In North America, the decision to perform TIPS involves gastroenterologists, hepatologists, and interventional radiologists, but TIPS creation is performed by interventional radiologists. This is in contrast to other parts of the world where TIPS creation is performed primarily by hepatologists. Thus, the successful use of TIPS in North America is dependent on a multidisciplinary approach and technical expertise, so as to optimize outcomes. Recently, new procedural techniques, TIPS stent technology, and indications for TIPS have emerged. As a result, practices and outcomes vary greatly across institutions and significant knowledge gaps exist. In this consensus statement, the Advancing Liver Therapeutic Approaches group critically reviews the application of TIPS in the management of portal hypertension. Advancing Liver Therapeutic Approaches convened a multidisciplinary group of North American experts from hepatology, interventional radiology, transplant surgery, nephrology, cardiology, pulmonology, and hematology to critically review existing literature and develop practice-based recommendations for the use of TIPS in patients with any cause of portal hypertension in terms of candidate selection, procedural best practices and, post-TIPS management; and to develop areas of consensus for TIPS indications and the prevention of complications. Finally, future research directions are identified related to TIPS for the management of portal hypertension.

Purpose To determine the safety and feasibility of pancreatic retrograde venous infusion (PRVI) utilizing a microvalvular infusion system (MVI) to deliver ethiodized oil (lipiodol) by means of the Pressure-Enabled Drug Delivery (PEDD) approach. Methods Utilizing transhepatic access, mapping of the pancreatic body and head venous anatomy was performed in 10 swine. PEDD was performed by cannulation of veins in the head (n = 4) and body (n = 10) of the pancreas with a MVI (Surefire® Infusion System (SIS), Surefire Medical, Inc (DBA TriSalus™ Life Sciences)) followed by infusion with lipiodol. Sets of animals were killed either immediately (n = 8) or at 4 days post-PRVI (n = 2). All pancreata were harvested and studied with micro-CT and histology. We also performed three-dimensional volumetric/multiplanar imaging to assess the vascular distribution of lipiodol within the glands. Results A total of 14 pancreatic veins were successfully infused with an average of 1.7 (0.5–2.0) mL of lipiodol. No notable change in serum chemistries was seen at 4 days. The signal-to-noise ratio (SNR) of lipiodol deposition was statistically increased both within the organ in target relative to non-target pancreatic tissue and compared to extra pancreatic tissue (p Conclusions PEDD using the RVI approach for targeted pancreatic infusions is technically feasible and did not result in organ damage in this pilot animal study.

Purpose To assess the effectiveness of disposable radiation-absorbing surgical drapes on operator radiation dose during transjugular liver biopsy (TJLB). Materials and Methods This dual-arm prospective, randomized study was conducted between May 2017 and January 2018 at a single institution. TJLB procedures (N = 62; patient age range, 19–80 y) were assigned at a 1:1 ratio to the use of radiation-absorbing surgical drapes or standard surgical draping. The primary outcome was cumulative radiation equivalent dose incident on the operator, as determined by an electronic personal dosimeter worn at the chest during each procedure. Cumulative kerma–area product (KAP), total fluoroscopy time, and total number of exposures used during each liver biopsy procedure were also determined. Results Mean radiation dose incident on the operator decreased by 56% with the use of radiation-absorbing drapes (37 μSv ± 35; range, 4–183 μSv) compared with standard draping (84 μSv ± 58; range, 11–220 μSv). Radiation incident on the patient was similar between groups, with no significant differences in mean KAP, total fluoroscopy time, and number of exposures acquired during the procedures. Conclusions Use of disposable radiation-absorbing drapes reduces scatter radiation to interventionalists performing TJLB.

Transarterial embolization is frequently used to treat local hepatocellular carcinoma (HCC). While various complications are known to occur following transarterial embolization, only one prior case of peritoneal spread of HCC occurring shortly after transarterial chemoembolization has been reported. We present five cases of peritoneal spread of HCC following transarterial embolization (including bland embolization, conventional transarterial chemoembolization (TACE), and doxorubicin-eluting beads TACE) and identify features common among those cases. Search of electronic radiology reports and images identified five patients with imaging before and after treatment of HCC with transarterial embolization and with newly developed peritoneal metastases after treatment. Various patient demographics and tumor characteristics were noted. The mean maximal diameter of the treated HCC tumors was 3.7 cm (range 1.4–11.9 cm). Three of the patients had ascites and treated tumors in the posterior right hepatic lobe, and all patients had subcapsular tumors treated with transarterial embolization before developing peritoneal metastases. The mean time from treatment with transarterial embolization to the development of peritoneal metastases was four months. Intraperitoneal metastatic disease should be considered a rare but potential complication of transarterial embolization of subcapsular HCC, particularly in patients with ascites and tumors that are in the posterior segments of the right lobe. This potential complication should perhaps be considered when planning transarterial HCC treatment, and radiologists interpreting imaging after transarterial embolization of HCC should assess for peritoneal metastases.

Intravenous (IV) contrast material is used extensively for CT and MRI scans done in emergency departments (ED). Its use is essential to make many critical diagnoses in ED patients. While adverse reactions can occur, newer research has added to our knowledge of IV contrast media tolerance and safety leading to improved and more liberal guidelines for intravenous contrast use. The updated information described in this review article indicates how intravenous contrast can be used safely in more patients, more expeditiously and with fewer precautions than with prior guidelines. This review article explains the basis for the new recommendations for intravenous contrast material use and describes indicated precautions and preparations to avoid adverse reactions for iodinated agents used for CT and gadolinium agents for MRI.

Purpose To assess safety and efficacy of doxorubicin drug-eluting embolic (DEE) transarterial chemoembolization of hepatocellular carcinoma (HCC) by extrahepatic collateral arteries. Materials and Methods Records of 177 patients with HCC who underwent 338 consecutive DEE chemoembolization procedures from 2011 to 2014 were retrospectively reviewed. A subgroup of 16 patients (13 men, 3 women, median age 66 y) underwent 24 procedures for 17 HCCs via extrahepatic arteries and was included in the study. Median tumor size was 3.1 cm (range, 1.0–10.3 cm). Extrahepatic collaterals included right inferior phrenic (19 procedures; 12 patients), adrenal (4 procedures; 3 patients), and cystic arteries (2 procedures; 2 patients). Radiographic response was assessed by Modified Response Evaluation Criteria in Solid Tumors criteria. Complications were defined by National Cancer Institute Common Terminology Criteria for Adverse Events. Results DEE chemoembolization achieved stable disease in 6 (35.3%), partial response in 6 (35.3%), and complete response in 4 (23.5%) HCCs. Disease progression was ultimately observed in 8 tumors (47.1%), with mean time to progression of 8.3 months after chemoembolization (range, 2–13 mo). Three minor and 5 major complications occurred in 8 patients; 2 minor complications were rash in vascular distribution after right inferior phrenic artery DEE chemoembolization. The 5 major complications were transient hepatotoxicity that resolved within 4–80 days; 1 was accompanied by pleural effusion requiring hospitalization. A mean 13.4 months after DEE chemoembolization, 67% of transplant candidates proceeded to liver transplant. Conclusions DEE transarterial chemoembolization via extrahepatic collaterals was effective and facilitated bridging to transplant. It was generally well tolerated; transient hepatotoxicity was the most common major complication.

Nicholas Fidelman,1 Curt Johanson,1 Maureen P Kohi,1 K Pallav Kolli,1 Ryan M Kohlbrenner,1 Evan D Lehrman,1 Andrew G Taylor,1 R Kate Kelley,2 Francis Y Yao,3 John P Roberts,4 Robert K Kerlan11Department of Radiology and Biomedical Imaging; 2Department of Medicine – Division of Gastrointestinal Oncology; 3Department of Medicine – Division of Hepatology; 4Department of Surgery – Division of Transplant Surgery, University of California San Francisco, San Francisco, CA, USAPurpose: To determine whether chemoembolization using drug-eluting beads (DEB-TACE) is safe and effective for liver transplantation candidates with liver-limited hepatocellular carcinoma (HCC) without vascular invasion and baseline hepatic dysfunction.Materials and methods: Seventeen adult liver transplantation candidates (median age 66 years, range 58–73 years; 13 men) with HCC were treated with DEB-TACE as a part of Stage 1 of a prospective single-institution Phase II trial. All patients had marginal hepatic reserve based on at least one of the following criteria: ascites (n=14), bilirubin between 3 and 6 mg/dL (n=5), AST 5–10 times upper normal limit (n=1), INR between 1.6 and 2.5 (n=4), portal vein thrombosis (n=2), and/or portosystemic shunt (n=2). Primary study objectives were safety and best observed radiographic response.Results: Thirty-seven DEB-TACE procedures were performed. Objective response rate and disease control rate were 63% and 88%, respectively. HCC progression was observed in 12 patients. Median time to progression was 5.6 months (range 0.9–13.6 months). Within 1 month following DEB-TACE, 13 patients (76%) developed grade 3 or 4 AE attributable to the procedure. Four patients (all within Milan Criteria) were transplanted (2.7–6.9 months after DEB-TACE), and 12 patients died (1.8–32 months after DEB-TACE). All deaths were due to liver failure that was either unrelated to HCC (n=5), in the setting of metastatic HCC (n=5), or in the setting of locally advanced HCC (n=2). Mortality rate at 1 month was 0%.Conclusions: DEB-TACE achieves tumor responses but carries a high risk of hepatotoxicity for liver transplant candidates with HCC and marginal hepatic reserve.Keywords: hepatocellular carcinoma, chemoembolization, liver transplantation

To evaluate radiation dose reduction in patients undergoing transarterial chemoembolization with the use of a new image acquisition and processing platform.Radiation-dose data were obtained from 176 consecutive chemoembolization procedures in 135 patients performed in a single angiography suite. From January 2013 through October 2013, 85 procedures were performed by using our institution's standard fluoroscopic settings. After upgrading the x-ray fluoroscopy system with an image acquisition and processing platform designed to reduce image noise and reduce skin entrance dose, 91 chemoembolization procedures were performed from November 2013 through December 2014. Cumulative dose-area product (CDAP), cumulative air kerma (CAK), and total fluoroscopy time were recorded for each procedure. Image quality was assessed by three interventional radiologists blinded to the x-ray acquisition platform used.Patient radiation dose indicators were significantly lower for chemoembolization procedures performed with the novel imaging platform. Mean CDAP decreased from 3,033.2 dGy·cm(2) (range, 600.3-9,404.1 dGy·cm(2)) to 1,640.1 dGy·cm(2) (range, 278.6-6,779.9 dGy·cm(2); 45.9% reduction; P.00001). Mean CAK decreased from 1,445.4 mGy (range, 303.6-5,233.7 mGy) to 971.7 mGy (range, 144.2-3,512.0 mGy; 32.8% reduction; P.0001). A 20.3% increase in mean total fluoroscopy time was noted after upgrading the imaging platform, but blinded analysis of the image quality revealed no significant degradation.Although a small increase in fluoroscopy time was observed, a significant reduction in patient radiation dose was achieved by using the optimized imaging platform, without image quality degradation.

Purpose To determine clinical outcomes of patients who underwent imaging-guided percutaneous drainage of breast fluid collections after mastectomy and breast reconstruction. Materials And Methods A retrospective review was performed including all consecutive patients who underwent percutaneous drainage of fluid collections after mastectomy with tissue expander–based reconstruction between January 2007 and September 2012. During this period, 879 mastectomies (563 patients) with expander-based breast reconstruction were performed. Fluid collections developed in 28 patients (5%), which led to 30 imaging-guided percutaneous drainage procedures. The median follow-up time was 533 days. Patient characteristics, surgical technique, microbiology analysis, and clinical outcomes were reviewed. Results The mean age of patients was 51.5 years (range, 30.9–69.4 y), and the median time between breast reconstruction and drainage was 35 days (range, 4–235 d). Erythema and swelling were the most common presenting symptoms. The median volume of fluid evacuated at the time of drain placement was 70 mL. Drains were left in place for a median 14 days (range, 6–34 d). Microorganisms were detected in the fluid in 12 of 30 drainage procedures, with Staphylococcus aureus being the most common microorganism. No further intervention was needed in 21 of 30 drainage procedures (70%). However, surgical intervention (removal of expanders) was needed after 6 (20%) drainage procedures, and additional percutaneous drainage procedures were performed after 3 (10%) drainage procedures. Conclusions Percutaneous drainage is an effective means of treating postoperative fluid collections after expander-based breast reconstruction and can obviate the need for repeat surgery in most cases.

Purpose To assess radiation dose reduction during uterine fibroid embolization (UFE) using an optimized angiographic processing and acquisition platform. Materials and Methods Radiation dose data for 70 women (mean age, 46 y; range, 34–67 y) who underwent UFE were retrospectively analyzed. Twenty-one patients underwent UFE using the baseline fluoroscopic and angiographic image acquisition platform, and 49 underwent UFE after implementing an optimized imaging platform in otherwise identical angiography suites. Cumulative kerma-area product (CKAP), cumulative air kerma (CAK), total fluoroscopy time, and image exposure number were collected for each procedure. Image quality was assessed by 3 interventional radiologists blinded to the platform used for image acquisition and processing. Results Patients undergoing UFE using the new x-ray fluoroscopy platform had significantly lower CKAP and CAK indicators than patients for whom baseline settings were used. Mean CKAP decreased by 60% from 438.5 Gy · cm 2 (range, 180.3–1,081.1 Gy · cm 2 ) to 175.2 Gy · cm 2 (range, 47.1–757.0 Gy · cm 2 ; P P = .001). No degradation of image quality was identified through qualitative evaluation. Conclusions Significant reduction in patient radiation dose indicators can be achieved with use of an optimized image acquisition and processing platform.

The purpose of this study was to test the potential of clinical imaging modalities, 64-slice multidetector computed tomography (MDCT) and 1.5T magnetic resonance imaging (MRI) for qualitative and quantitative evaluation of acute microinfarcts and to determine the effects of

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related deaths worldwide.1 Treatment options depend on the tumor stage and liver function.2 Resection, thermal ablation, and liver transplantation are the only potentially curative options.3 Candidacy for transplantation is based on the Milan criteria [1 lesion ≤5 cm or 2 to 3 lesions ≤3 cm in diameter without macrovascular invasion as determined by multiphase contrast-enhanced (CE) computed tomography (CT) or magnetic resonance imaging (MRI)].4 Liver-directed therapy, such as transarterial chemoembolization (TACE) and thermal ablation, is offered to patients with unresectable HCC confined to the liver as a bridge to transplantation.5,6 Local and distal tumor recurrences as well as the presence of a residual disease after liver-directed therapy are common and are among the causes of dropout from the transplant list and high mortality.7,8 Therefore, identifying and treating recurrent lesions is imperative for maintaining patients’ eligibility while they are awaiting transplantation.5 The diagnosis of HCC is often based on a characteristic tumor appearance on CE CT or MRI. Tissue diagnosis is usually not required.3,9 Because CE CT and MRI scans reliably detect only HCC nodules larger than 1 cm and may underestimate the tumor stage,10,11 an alternative diagnostic imaging tool that can detect additional lesions may improve clinical outcomes.12 One diagnostic tool that is already employed for some patients with HCC is hepatic digital subtraction angiography (DSA), which is performed in conjunction with arterial therapies used to treat HCC. The sensitivity of DSA for HCC detection has been reported to be in the range of 55% to 77%13–15 and is better for larger HCC lesions.16 The sensitivity of CE CT and MRI for HCC detection has been described to be in the 65% to 84%10,11,14,15 and 62% to 76% ranges,10,11,14 respectively. In comparison, the sensitivity for the demonstration of ethiodized oil (lipiodol) uptake after TACE in HCC lesions on plain post-TACE radiographs has been reported at 94%,17 whereas the sensitivity of postlipiodol CT for the detection of hypervascular HCC lesions treated with TACE may approach 100%.18 Angiographic images sometimes demonstrate hypervascular foci in the liver that outnumber the lesions detected by CE CT or MRI.19 Conversely, sometimes there is no angiographic correlate to hypervascular lesions detected on cross-sectional imaging. The clinical significance of these “discordant” findings is unclear. The purpose of this study was to retrospectively review and correlate findings during hepatic DSA obtained at the time of TACE with preceding CE CT and/or MRI in patients with HCC listed for liver transplantation in order to identify patients with discordant lesions and to determine whether the presence of such lesions led to adverse clinical outcomes, such as removal from the transplant list and post-transplant tumor recurrence.

Background Right adrenal vein (RAV) catheterization can be a very challenging step in adrenal venous sampling (AVS). Visualization of the inferior emissary vein (IEV) may be an indication of successful RAV catheterization. Purpose To compare the rate of successful RAV sampling in the presence of the IEV. Material and Methods Retrospective review of all consecutive patients with PA who underwent AVS between April 2009 and April 2012 was performed. A total of 30 patients were identified. Procedural images, cortisol, and aldosterone values obtained from sampling of the RAV and inferior vena cava (IVC) were reviewed. Cortisol measurements obtained from RAV samples were divided by measurements from the infra-renal IVC blood samples in order to calculate the selectivity index (SI). An SI >3 was considered indicative of technically successful RAV sampling. Results RAV sampling was considered technically successful in 29 out of 30 cases (97%). In cases of successful RAV sampling (29 patients), the IEV was identified in 25 patients (86%). The IEV was visualized in isolation in 16 patients (64%), and in conjunction with visualization of the RAV or right adrenal gland stain in nine patients (36%). The IEV was not visualized in the one case of unsuccessful RAV sampling. Visualizing the IEV had a sensitivity of 86.2% for successful RAV sampling. Conclusion The IEV may serve as a reliable landmark for the RAV during RAV sampling.

Proinflammatory T helper 1 (Th1) cells express high levels of carbohydrate ligands for the endothelial selectins, but the molecular basis for this phenotype is incompletely understood. We document here a significant role in selectin ligand formation for the recently described Th1 transcription factor T-bet. Th1 cells generated from T-bet-/- mice showed significantly lower levels of ligands for both E-selectin and P-selectin, compared with wild-type (WT) Th1 cells. Enforced expression of T-bet in WT Th0 cells only modestly up-regulated P-selectin ligands and had no effect on E-selectin ligands. To define a mechanism for the defects observed in T-bet-/- mice, we examined expression of glycosyltransferases involved in selectin ligand biosynthesis. T-bet-/- Th1 cells expressed significantly lower levels of core 2 β1,6 N-acetylglucosaminyltransferase I (C2GlcNAcT-I), but no differences in levels of α 2,3-sialyltransferase IV (ST3Gal-IV). Further, we show that T-bet is responsible for the signal transducer and activator of transcription 4 (Stat4)–independent increase in Th1 cells of fucosyltransferase VII (FucT-VII). We also identify ST3Gal-VI, which is thought to play an important role in E- and P-selectin ligand formation, as an interleukin 12 (IL-12)–regulated, T-bet–dependent gene. These data show that T-bet controls selectin ligand formation in Th1 cells via control of expression of multiple key enzymes in response to IL-12 signaling and establishes an independent transcriptional pathway for control of Th1 cell traffic.

Inferior vena cava (IVC) filter placement is indicated for patients with pulmonary embolism and/or deep venous thrombosis when anticoagulation therapy is contraindicated. IVC filter placement, however, is not without complications. In this case, we noted crossing of the filter struts immediately after deployment of the ALN IVC filter (ALN Implants Chirurgicaux Ghisonaccia, France). The filter was then successfully removed.

Editor: Despite efforts to minimize the incidence of retained surgical instruments, this complication continues to occur in approximately 1 in 8,000–18,000 of all operations (1). Preoperative localization of breast lesions with a hook wire has become a standard radiologic practice (2). This technique is advantageous because the needle is accurately positioned under imaging guidance, and when deployed, the hook maintains the wire in position until the patient can undergo surgical resection of the suspicious lesion. We describe a case of a retained suture needle in the perineum that was successfully localized using a hook wire (Modified Kopans; Cook, Inc, Bloomington, Indiana) and subsequently retrieved. Institutional review board approval was not required for this single retrospective case report. A 30-year-old woman presented to our institution with pain and purulent discharge from her perineum 6 days following a forceps-assisted vaginal delivery with second-degree perineal laceration. On examination, necrotic tissue was present at the edges of the prior laceration repair site, and purulent material was draining from the wound. She underwent incision, debridement, and packing of the wound, in anticipation of a secondary wound closure. During the secondary wound closure procedure, the tissues were approximated using 3-0 polyglactin 910 (VICRYL RAPIDE; Ethicon, Inc, Somerville, New Jersey) sutures. During performance of the crown stitch portion of wound closure, the tip of the suture needle was visualized in the perineal soft tissues, but it could not to be grasped with pickups or a needle driver. Smooth pickups were used to grasp the suture near the base of the needle. When this area of the suture was grasped, the suture detached from the needle, and the needle remained buried in the perineal soft tissues and was not visible or palpable. Limited intraoperative ultrasound of the wound and the perineal soft tissues did not localize the needle. Extensive wound exploration and dissection were not performed because of the patient’s recent history of perineal abscess. Hook wire localization was performed using a helical computed tomography (CT) scanner (HiSpeed Advantage; General Electric Medical Systems, Milwaukee, Wisconsin). An initial CT scan through the right perineum was obtained so that the entry skin site, depth, and angulation of the hook wire needle could be planned with respect to the retained suture needle (Fig 1). The length of the hook wire was determined by the depth required to reach the retained suture needle from the skin surface plus an additional 1.5 cm to position the stiff portion of the hook wire adjacent to the retained suture needle. Using serial CT scans to confirm location, the hook wire needle was positioned past the retained suture needle, and the hook wire was deployed; additional CT images confirmed final placement (Fig 2). The portion of the hook wire external to the patient was secured to the patient with gauze and tape. In the operating room, a sharp dissection from the edge of the vaginal wall in the direction of the hook wire was performed, and the retained suture needle was located and retrieved along with the hook wire. The perineum

This prospective pilot single-institution study was undertaken to document the feasibility, safety, and efficacy of treatment of liver-dominant metastatic gastrointestinal cancer using (90)Y glass microspheres.Between June 2010 and November 2012, 30 adult patients (22 men, eight women; median age 61 years) with metastatic chemotherapy-refractory unresectable colorectal (n = 15), neuroendocrine (n = 9), intrahepatic cholangiocarcinoma (n = 3), pancreas (n = 2), and esophageal (n = 1) carcinomas underwent 45 lobar or segmental administrations of (90)Y glass microspheres. Data regarding clinical and laboratory adverse events (AE) were collected prospectively for 6 months after each treatment. Radiographic responses were evaluated using Response Evaluation Criteria in Solid Tumors, version 1.1. Time to maximum response, response duration, progression-free survival (hepatic and extrahepatic), and overall survival were measured.Median target dose and activity were 111.6 Gy and 2.5 GBq per treatment session, respectively. All but three clinical AE were grade 1 or 2 in severity. Serious AE included an unplanned hospital admission for carcinoid crisis, grade 3 vomiting, and grade 4 gastric ulcer. Patients with colorectal cancer had hepatic objective response rate (ORR) of 27 % and a disease control rate (DCR) of 73 %. Median progression-free and overall survival were 1.0 and 4.9 months, respectively. Patients with neuroendocrine tumors had hepatic ORR and DCR of 78 % and 100 %, respectively. Median progression-free survival was 18.5 months for this cohort.Y glass microspheres device has a favorable safety profile and achieved prolonged disease control of hepatic tumor burden in a subset of patients, including all patients enrolled in the neuroendocrine cohort.

Purpose: To compare treatment response after transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) in patients with and without a transjugular intrahepatic portosystemic shunt (TIPS). Materials and Methods: A retrospective review of patients who underwent conventional TACE for HCC between January 2005 and December 2009 identified 10 patients with patent TIPS. From the same time period, 23 patients without TIPS were selected to control for comparable Model for End-Stage Liver Disease and Child-Pugh-Turcotte scores. The two groups showed similar distribution of Barcelona Clinic Liver Cancer and United Network of Organ Sharing stages. Target HCC lesions were evaluated according to the modified response evaluation criteria in solid tumors (mRECIST) guidelines. Transplantation rate, time to tumor progression, and overall survival (OS) were documented. Results: After TACE, the rate of complete response was significantly greater in non-TIPS patients compared with TIPS patients (74 vs. 30 %, p = 0.03). Objective response rate (complete and partial response) trended greater in the non-TIPS group (83 vs. 50 %, p = 0.09). The liver transplantation rate was 80 and 74 % in the TIPS and non-TIPS groups, respectively (p = 1.0). Time to tumor progression was similar (p = 0.47) between the two groups. OS favored the non-TIPS group (p = 0.01) when censored for liver transplantation. Conclusion: TACE is less effective in achieving complete or partial response using mRECIST criteria in TIPS patients compared with those without a TIPS. Nevertheless, similar clinical outcomes may be achieved, particularly in TIPS patients who are liver-transplantation candidates. © 2013 Springer Science+Business Media New York and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE).

Antibody-secreting plasma cells represent the critical end-stage effector cells of the humoral immune response. Here, we show that several distinct plasma cell subsets are concurrently present in the lymph nodes, spleen, and bone marrow of mice deficient in both E- and P-selectin. One of these subsets was a B220-negative immunoglobulin g (IgG) plasma cell population expressing low to negative surface levels of syndecan-1. Examination of the chemotactic responsiveness of IgG plasma cell subsets revealed that migration toward stromal cell-derived factor 1/CXC ligand 12 (SDF-1/CXCL12) was primarily limited to the B220-lo subset regardless of tissue source. Although B220-negative plasma cells did not migrate efficiently in response to CXCL12 or to other chemokines for which receptor mRNA was expressed, these cells expressed substantial surface CXC chemokine receptor-4 (CXCR4), and CXCL12 stimulation rapidly induced extracellular signal regulated kinase 1 (ERK1)/ERK2 phosphorylation, demonstrating that CXCR4 retained signaling capacity. Therefore, B220-negative plasma cells exhibit a selective uncoupling of chemokine receptor expression and signaling from migration. Taken together, our findings document the presence of significant heterogeneity within the plasma cell compartment, which suggests a complex step-wise scheme of plasma cell differentiation in which the degree of differentiation and tissue location can influence the chemotactic responsiveness of IgG plasma cells. (Blood. 2003;102:4076-4083)