Role of transcatheter arterial embolization for massive bleeding from gastroduodenal ulcers

Intractable bleeding from gastric and duodenal ulcers is associated with significant morbidity and mortality. Aggressive treatment with early endoscopic hemostasis is essential for a favourable outcome. In as many as 12%-17% of patients,endoscopy is either not available or unsuccessful. Endovascular therapy with selective catheterization of the culprit vessel and injection of embolic material has emerged as an alternative to emergent operative intervention in high-risk patients. There has not been a systematic literature review to assess the role for embolotherapy in the treatment of acute upper gastrointestinal bleeding from gastroduo-denal ulcers after failed endoscopic hemostasis. Here,we present an overview of indications,techniques,and clinical outcomes after endovascular embolization of acute peptic-ulcer bleeding. Topics of particular relevance to technical and clinical success are also discussed. Our review shows that transcatheter arterial embolization is a safe alternative to surgery for massive gastroduodenal bleeding that is refractory to endoscopic treatment,can be performed with high technical and clinical success rates,and should be considered the salvage treatment of choice in patients at high surgical risk.

Juxta-caval hepatic angiomyolipoma masquerading as hepatocellular carcinoma

Hepatic angiomyolipoma is an uncommon primary benign epithelial liver neoplasm. Most patients with angiomyolipomas are middle-aged women who commonly present with epigastric fullness or pain. Angiomyolipomas are tumors consisting of three tissue types: blood vessels, smooth muscle, and fat. Hepatic angiomyolipomas may be difficult to differentiate from other liver neoplasms by noninvasive imaging. We report a 58-year-old asymptomatic woman with a mass in the right lobe of the liver, found incidentally on routine abdominal sonography. Preoperative radiographic evaluation revealed a 6.5-cm hypervascular lesion abutting the inferior vena cava. Preoperative histologic study demonstrated an epithelial neoplasm suspicious for hepatocellular carcinoma. Metastatic workup was negative. At resection, the tumor was found to be an angiomyolipoma composed of lipoid, vascular and smooth muscle cells. Further staining was positive for HMB-45. Resection margins were negative. The woman had an uneventful recovery and was discharged on postoperative day seven. She currently remains well several months after her right hepatectomy.

Predicting Infiltrative Hepatocellular Carcinoma Patient Outcome Post-TACE:MR Bias Field Correction Effect on 3D-quantitative Image Analysis

Background and Aims:To investigate the impact of MR bias field correction on response determination and survival prediction using volumetric tumor enhancement analysis in patients with infiltrative hepatocellular carcinoma,after transcatheter arterial chemoembolization(TACE).Methods:This study included 101 patients treated with conventional or drug-eluting beads TACE between the years of 2001 and 2013.Semi-automated 3D quantification software was used to segment and calculate the enhancing tumor volume(ETV)of the liver with and without bias-field correction on multi-phasic contrast-enhanced MRI before and 1-month after initial TACE.ETV(expressed as cm3)at baseline imaging and the relative change in ETV(as%change,ETV%)before and after TACE were used to predict response and survival,respectively.Statistical survival analyses included Kaplan-Meier curve generation and Cox proportional hazards modeling.Q statistics were calculated and used to identify the best cut-off value for ETV to separate responders and non-responders(ETV cm3).The difference in survival was evaluated between responders and non-responders using Kaplan-Meier and Cox models.Results:MR bias field correction correlated with improved response calculation from baseline MR as well as survival after TACE;using a 415 cm3 cut-off for ETV at baseline(hazard ratio:2.00,95%confidence interval:1.23-3.26,p=0.01)resulted in significantly improved response prediction(median survival in patients with baseline ETV<415 cm3:19.66 months vs.≥415 cm3:9.21 months,p<0.001,log-rank test).A≥41%relative decrease in ETV(hazard ratio:0.58,95%confidence interval:0.37-0.93,p=0.02)was significant in predicting survival(ETV≥41%:19.20 months vs.ETV<41%:8.71 months,p=0.008,log-rank test).Without MR bias field correction,response from baseline ETV could be predicted but survival after TACE could not.Conclusions:MR bias field correction improves both response assessment and accuracy of survival prediction using whole liver tumor enhancement analysis from baseline MR after initial TACE in patients with infiltrative hepatocellular carcinoma.