Castleman Disease of the Kidney in Computed Tomography Urography

Background: Castleman disease (CD) of the kidney is extremely rare. In this study, we presented a case of CD of the left kidney and comprehensively described the findings of computed tomography urography. Case Presentation: The case involved unusual imaging characteristics of the focal central cystic area. Conclusion: The small and regular cyst-like structures and the hyperdense mass relative to the renal parenchyma in plain scans might help distinguish the CD of the kidney from other hypervascular tumors.

Preoperative obliteration of choroidal arteries in the treatment of large hypervascular tumors in the lateral ventricle

Background Removal of large hypervascular tumors in the lateral ventricle still poses a surgical challenge. These tumors are usually fed from choroidal arteries, and vascular control is typically performed late during the removal. We aimed to evaluate the clinical efficacy of our strategy for persistent preoperative obliteration of feeders from the choroidal arteries to manage large hypervascular tumors in the lateral ventricle. Methods We retrospectively analyzed six patients with hypervascular tumors in the lateral ventricle. We first attempted to obstruct feeders using endovascular treatment, and, if unavailable, performed initial microsurgical occlusion through the temporal horn for the staged tumor removal. Results In all patients, feeder obliteration was successfully performed; the anterior choroidal arteries were occluded by the endovascular treatment and microsurgical occlusion in one and five patients, respectively, while the lateral posterior choroidal arteries were occluded via endovascular treatment in four patients. No patients had permanent symptoms due to feeder obliteration, and tumor devascularization was achieved at the mean rate of 69.9%. During the tumor removal, the mean blood loss volume was 253 ml. No postoperative hemorrhage had occurred, and all patients scored ≤ 2 on the modified Rankin Scale at six months post-removal. Conclusions Although further studies are warranted, persistent feeder obliteration of choroidal arteries could be an effective treatment strategy against large hypervascular tumors in the lateral ventricle.

Trends in Utilization of Preoperative Embolization for Spinal Metastases: A Study of the National Inpatient Sample 2005–2017

Purpose: While previous studies have suggested that preoperative embolization of hypervascular spinal metastases may alleviate intraoperative blood loss and improve resectability, trends and driving factors for choosing this approach have not been extensively explored. Therefore, we evaluated the trends and assessed the factors associated with preoperative embolization utilization for spinal metastatic tumors using a national inpatient database.Materials and Methods: The National Inpatient Sample database of the Healthcare Cost and Utilization Project was queried for patients undergoing surgical resection for spinal metastasis between January 1, 2005 and December 31, 2017. Patients undergoing preoperative embolization were identified; trends in the utilization of preoperative embolization were analyzed using the Cochran-Armitage test. Multivariable regression was conducted to assess factors associated with higher preoperative embolization utilization.Results: A total of 11,508 patients with spinal metastasis were identified; 105 (0.91%) underwent preoperative embolization. Of those 105 patients, 79 (75.24%) patients had a primary renal cancer, as compared to 1,732 (15.19%) of those who did not undergo preoperative embolization (P<0.001). The majority of patients in the non-preoperative embolization cohort had a primary lung tumor (n=3,562, 31.24%). Additionally, patient comorbidities were similar among the 2 groups (P>0.05). Trends in preoperative embolization indicated an increase of 0.16% (standard error: 0.024%, P<0.001) in utilization per year.Conclusion: Utilization of preoperative embolization for spinal metastasis is increasing yearly, especially for patients with renal cancer, suggesting that surgeons may increasingly consider embolization before surgical resection for hypervascular tumors. Additionally, the literature has shown the intraoperative and postoperative benefits of this procedure.

Only Tumors Angiographically Identified as Hypervascular Exhibit Lower Intraoperative Blood Loss Upon Selective Preoperative Embolization of Spinal Metastases: Systematic Review and Meta-Analysis

BackgroundThe role of preoperative embolization (PE) in reducing intraoperative blood loss (IBL) during surgical treatment of spinal metastases remains controversial.MethodsA systematic search was conducted for retrospective studies and randomized controlled trials (RCTs) comparing the IBL between an embolization group (EG) and non-embolization group (NEG) for spinal metastases. IBL data of both groups were synthesized and analyzed for all tumor types, hypervascular tumor types, and non-hypervascular tumor types.ResultsIn total, 839 patients in 11 studies (one RCT and 10 retrospective studies) were included in the analysis. For all tumor types, the average IBL did not differ significantly between the EG and NEG in the RCT (P = 0.270), and there was no significant difference between the two groups in the retrospective studies (P = 0.05, standardized mean difference [SMD] = −0.51, 95% confidence interval [CI]: −1.03 to 0.00). For hypervascular tumors determined as such by consensus (n = 542), there was no significant difference between the two groups (P = 0.52, SMD = −0.25, 95% CI: −1.01 to 0.52). For those determined as such using angiographic evidence, the IBL was significantly lower in the EG than in the NEG group, in the RCT (P = 0.041) and in the retrospective studies (P = 0.004, SMD = −0.93, 95% CI: −1.55 to −.30). For IBL of non-hypervascular tumor types, both the retrospective study (P = 0.215) and RCT (P = 0.947) demonstrated no statistically significant differences in IBL between the groups.ConclusionsOnly tumors angiographically identified as hypervascular exhibited lower IBL upon PE in this study. Further exploration of non-invasive methods to identify the vascularity of tumors is warranted.

The feasibility of degradable glass microspheres as transient embolic medical devices

The deliberate occlusion of blood flow through transarterial embolization is currently being used to treat conditions ranging from hemorrhages to hypervascular tumors. Degradable, imageable high borate glass microspheres (BRS2) were developed and tested to improve lesion targeting and promote a temporary vascular occlusion which is sufficient for most embolization procedure. A 48 hour pilot study, in a swine renal model, was conducted to assess the embolization effectiveness and potential risks of this new embolic agent. Bilateral embolization of the caudal branch of the renal arteries using test and control particles were performed in 4 pigs. Embolization efficacy, recanalization and resulting ischemia were evaluated at different time frame (0, 24 and 48 hours). The primary outcomes for this study were the assessment of: (i) embolization effectiveness, and (ii) vessel recanalization. The test article was found to occlude vessels as effectively as the control microspheres, with the use of a smaller volume of microspheres. At the 24 hour time point, over 95% of the material was found to be completely degraded, although little to no recanalization was observed. This data suggests that BRS2 is an effective embolic agent, however further investigations into the method of delivery are required prior to clinical implementation.

Pre-operative direct puncture embolization of head and neck hypervascular tumors using SQUID 12

Objective The authors have evaluated their experience in pre-operative direct puncture embolization of hypervascular tumors of the head and neck using SQUID 12, an embolic liquid agent. Methods Between July 2016 and March 2019, the authors retrospectively reviewed clinical, embolization and surgical data of 11 consecutive patients with 12 hypervascular head and neck tumors who had undergone pre-operative embolization using SQUID 12. Percutaneous embolizations were performed by inserting a 19-22 Gauge needle directly into the tumor under ultrasound, fluoroscopic and/or endoscopic guidance. The hub of the needle was connected to a 15-cm DMSO-compatible extension tube, and the SQUID 12 was injected. Results Total or near-total devascularization was achieved in 11 over 12 cases. Complete en-bloc tumor removal by surgery was achieved in all cases. Only one patient required blood transfusion. No major periprocedural adverse events were recorded. Conclusions Direct puncture embolization of hypervascular tumors of the head and neck using SQUID 12 seems to be safe and effective. It may offer almost complete devascularization due to homogenous, deep penetration in the tumor, with optimal visibility of the agent throughout the percutaneous procedure. It may reduce intraoperative blood loss and the need for transfusion, thus facilitating complete surgical resection.

Scapular Metastasis by Rcc. Case Presentation

Bony metastasis is a frequent occurrence in malignancies. We present the case of a 75-year-old male patient who was investigated for a lytic lesion in the right scapula and was eventually diagnosed with metastatic renal cell carcinoma (RCC). The main indications for embolization are reducing the risk of bleeding during and after surgery of hypervascular tumors, simplifying the manipulation of tumors, palliation of pain, bleeding, fever, and hypercalcemia-like symptoms in inoperable tumors, preventing further dissemination of a tumor, and increasing the response to chemotherapy and radiotherapy. Embolization may be a therapeutic alternative to surgery in cases in which surgery is inappropriate or associated with high risk. In the case presented, CT examinations had a crucial role both in the diagnostic orientation and in the subsequent therapeutic decisions and proper monitoring under therapy.

Tumor Vascularity Does Not Predict Response to Yttrium-90 Radioembolization for Hepatic Metastases from Colorectal Cancer

The purpose of this study was to determine whether the degree of tumor vascularity based on imaging has an impact on tumor response and survival in patients with metastatic colorectal cancer (mCRC) to the liver undergoing yttrium-90 radioembolization. A retrospective study of 75 mCRC patients from a single-institution undergoing radioembolization was performed over a 7-year period. Tumors were categorized as hypo- or hypervascular based on digital subtraction angiography (DSA) and C-arm CT during mapping angiography. Tumor response and survival were compared between each group, after undergoing radioembolization. Hypervascular tumors were present in 37 of 75 (49%) patients according to DSA. Of 37 patients who underwent C-arm CT during the procedure, 22 (59%) had tumors classified as hypervascular. There were no significant differences in tumor response rates when vascularity was stratified by DSA or C-arm CT. Median progression-free survival (PFS) was 111 versus 128 days (p = 0.41) between DSA hypervascular and hypovascular cases, and median overall survival (OS) was 439 versus 342 days (p = 0.96). When stratified by C-arm CT, median PFS was 313 versus 244 days (p = 0.83) and median OS was 489 versus 342 days (p = 0.74) for hypervascular and hypovascular cases, respectively. Tumor vascularity based on DSA or C-arm CT does not predict imaging response or survival after radioembolization and should not be used as a criterion for selecting candidates for radioembolization for hepatic mCRC.