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BACKGROUND: Endovascular management of portal vein thrombosis (PVT) is challenging. Transsplenic access (TSA) is growing as an access option to the portal system but with higher rates of bleeding complications. The aim of this article is to evaluate the efficacy and safety of transsplenic portal vein recanalization (PVR) using a metallic stent after pediatric liver transplantation. MATERIALS AND METHODS: This is a retrospective review of 15 patients with chronic PVT who underwent PVR via TSA between February 2016 and December 2020. Two children who had undergone catheterization of a mesenteric vein tributary by minilaparotomy were excluded from the patency analysis but included in the splenic access analysis. The technical and clinical success of PVR and complications related to the procedure via TSA were evaluated. RESULTS: Thirteen children with PVT were treated primarily using the TSA. The mean age was 4.1 years (range, 1.5-13.7 years), and the most common clinical presentation was hypersplenism (60%). Technically successful PVR was performed in 11/13 (84.6%) children, and clinical success was achieved in 9/11 (81.8%) children. No major complications were observed, and one child presented moderate pain in the TSA (from a total of 17 TSA). The median follow-up was 48.2 months. The median primary patency was 9.9 months. Primary patency in the first 4 years was 75%, and primary assisted patency was 100% in the follow-up period. CONCLUSIONS: Transsplenic PVR is a safe and effective method for the treatment of PVT after pediatric liver transplantation.

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Introdução: A biópsia transtorácica percutânea guiada por tomografia computadorizada apesar de segura e eficaz, não fornece um detalhamento muitas vezes necessário para acesso a uma lesão pulmonar indeterminada suspeita de neoplasia primária na intenção de confirmação histopatológica. Métodos funcionais e metabólicos como a difusão por Ressonância Magnética (DW-RM) e Tomografia por Emissão de Pósitrons (PET-CT) após administração do F18-Fluorodesoxiglicose podem auxiliar na melhora dos resultados, permitindo direcionar a coleta da amostra para uma área de maior representatividade biológica. Objetivo: Verificar de forma prospectiva, a importância da imagem funcional e metabólica, através da utilização da DW-RM e do PET-CT, no resultado histopatológico obtido pela biópsia percutânea guiada por TC de lesões pulmonares indeterminadas suspeitas de neoplasia primária. Metodologia: Foram estudados, de forma prospectiva, 27 pacientes com lesões pulmonares indeterminadas, suspeitas para câncer de pulmão, sendo realizado de forma complementar a DW-RM ou o PET-CT. Foram coletadas amostras de duas áreas distintas de uma mesma lesão guiadas pelos valores locais de SUV e mapas de ADC formando-se duas áreas arbitrariamente definidas como de suspeição menor e maior para câncer. Resultados: Os pacientes que fizeram a DW-RM apresentaram lesões de tamanho mediano de 65,0 mm (37,0 - 75,0 mm). A área de maior suspeição obteve uma mediana de ADC de 1,17 x 10-3mm2/s (0,31 - 2,82 x 10-3mm2/s), enquanto a de menor suspeição uma mediana de 1,87 x 10-3mm2/s (1,00 - 3,44 x 10-3mm2/s; P=0,0001). Foram positivas para câncer 100% das amostras da área de maior suspeição e 71,43% das amostras da área de menor suspeição (P= 0,0184). Os pacientes que realizaram o PET-CT apresentaram lesões de tamanho mediano de 61,0 mm (42,0 - 87,0). A área de maior suspeição obteve uma mediana do SUV de 7,1 (2,3 - 10,9) e a área de menor suspeição de 3,9 (0,9 - 3,9; P= 0,0002). Foram positivos para câncer 76,9 % das amostras em ambas as áreas (P=0,0522). Conclusão: Os métodos diagnósticos utilizados neste estudo, PET-CT e DW-RM, mostraram que os tumores são funcional e metabolicamente heterogêneos, e que esta heterogeneidade tem implicações no diagnóstico histopatológico

Introduction: Computed tomography guided transcutaneous transthoracic biopsy, although safe and effective, does not provide enough detailing that is often necessary to access an indeterminate lung lesion suspected of lung cancer for the purpose of histopathological confirmation. Functional and metabolic methods such as Magnetic Resonance Diffusion (DW-RM) and Positron Emission Tomography (PET-CT) after administration of F18-Fluorodeoxyglucose may help improve the results, in addition to directing sample collection to a lesion area of greater biological representativeness. Objective: To prospectively verify the importance of functional and metabolic imaging, through the use of DW-MRI and PET-CT, in the histopathological results obtained by CT-guided percutaneous biopsy of indeterminate pulmonary lesions suspected of primary cancer. Methodology: Twenty-seven patients with indeterminate pulmonary lesions, suspected of lung cancer, were prospectively evaluated after have been performed in a complementary way the DW-MRI or PET-CT. Samples were collected from two different lesion areas guided by local SUV values and ADC maps forming two arbitrarily defined areas of lower and higher suspicion for cancer. Results: Patients who underwent DW-MRI had median lesion size of 65.0 mm (37.0 - 75.0 mm). The higher suspicion area had a median of ADC of 1.17 x 10-3 mm2 / s (0.31 - 2.82 x 10-3mm2 / s), while the lower suspicion area had a median of 1.87 x 10 -3mm2 / s (1.00 - 3.44x10-3mm2 / s; P = 0.0001). 100% of the samples from the higher suspicion area and 71.43% of the samples from the lower suspicion area (P = 0.0184) were positive for cancer. Patients who performed PET-CT had median lesion size of 61.0 mm (42.0 - 87.0). The higher suspicion area obtained a median SUV of 7.1 (2.3 - 10.9) and the lower suspicion area of 3.9 (0.9 - 3.9; P = 0.0002). 76.9% of the samples were positive for cancer in both areas (P = 0.0522). Conclusion: The diagnostic methods used in this study, PET-CT and DW-MRI, showed that tumors are functional and metabolically heterogeneous and that this heterogeneity has implications for histopathological diagnosis

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AIM: To evaluate the effects of HepaSphere 50-100 µm (Merit Medical) as a doxorubicin carrier and embolization agent for the treatment of hepatocellular carcinoma (HCC). MATERIAL AND METHODS: A prospective analysis of 18 patients recruited from a national cancer center was conducted. This analysis evaluated the efficacy and safety of HepaSphere, as expressed by the treatment response rate (measured by the modified Response Evaluation Criteria in Solid Tumors, mRECIST) and by the prevalence of treatment-related adverse events, respectively. RESULTS: The cohort was predominantly male, with a mean age of 69 years. The objective response rate (complete + partial response) was 53.3%. The variable most likely to be associated with objective response was Barcelona Clinic Liver Cancer (BCLC) staging. The most prevalent adverse events were nausea, vomiting and abdominal pain. CONCLUSION: HepaSphere chemoembolization yielded a substantial objective response rate with an acceptable toxicity profile and should be considered an option for HCC treatment.

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OBJECTIVE: This study aimed to compare two self-expanding stents, a nitinol stent and an elgiloy stent, both placed percutaneously, in terms of their efficacy in palliating inoperable malignant biliary obstruction. MATERIALS AND METHODS: We retrospectively investigated 99 patients with unresectable malignant biliary obstruction treated with percutaneous placement of a self-expanding metallic stent at our institution between May 2007 and January 2010. Serum bilirubin and liver enzyme levels were measured before and 30 days after stenting. For all procedures using elgiloy or nitinol stents, stent occlusion and patient survival rates were calculated using Kaplan-Meyer analysis. RESULTS: All of the patients showed clinical improvement after stent placement, with no difference between the two groups. In both groups, the occlusion-free survival rate was 67% at 30 days, 37% at 90 days, 25% at 180 days, and 10% at 360 days, with no significant difference in relation to the type of stent. CONCLUSION: The two stents evaluated showed comparable efficacy for the percutaneous treatment of unresectable biliary malignancy, with good clinical results.

OBJETIVO: Este estudo procurou comparar a eficácia do implante percutâneo do stent autoexpansível de nitinol versus o stent de elgiloy para paliação da obstrução biliar maligna irressecável. MATERIAIS E MÉTODOS: Nós investigamos, retrospectivamente, 99 pacientes com obstrução maligna irressecável tratada com implante percutâneo de stent metálico autoexpansível em nossa instituição, de março de 2007 até janeiro de 2010. Os níveis séricos de bilirrubina e enzimas hepáticas foram medidos antes e 30 dias após o implante do stent. Para os procedimentos em que foi utilizado o stent de elgiloy ou o stent de nitinol, as taxas de oclusão dos stents e as taxas de sobrevida dos pacientes foram calculadas pela análise de Kaplan-Meyer. RESULTADOS: Os pacientes mostraram melhora clínica após o implante dos stents, sem diferença entre os dois grupos. As taxas de sobrevida livre de oclusão foram 67% aos 30 dias, 37% aos 90 dias, 25% aos 180 dias e 10% aos 360 dias para ambos os grupos, sem diferença significativa em relação ao tipo de stent. CONCLUSÃO: Os dois stents mostraram eficácias comparáveis no tratamento da doença biliar maligna irressecável, com bons resultados clínicos.

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Abstract Objective: This study aimed to compare two self-expanding stents, a nitinol stent and an elgiloy stent, both placed percutaneously, in terms of their efficacy in palliating inoperable malignant biliary obstruction. Materials and Methods: We retrospectively investigated 99 patients with unresectable malignant biliary obstruction treated with percutaneous placement of a self-expanding metallic stent at our institution between May 2007 and January 2010. Serum bilirubin and liver enzyme levels were measured before and 30 days after stenting. For all procedures using elgiloy or nitinol stents, stent occlusion and patient survival rates were calculated using Kaplan-Meyer analysis. Results: All of the patients showed clinical improvement after stent placement, with no difference between the two groups. In both groups, the occlusion-free survival rate was 67% at 30 days, 37% at 90 days, 25% at 180 days, and 10% at 360 days, with no significant difference in relation to the type of stent. Conclusion: The two stents evaluated showed comparable efficacy for the percutaneous treatment of unresectable biliary malignancy, with good clinical results.

Resumo Objetivo: Este estudo procurou comparar a eficácia do implante percutâneo do stent autoexpansível de nitinol versus o stent de elgiloy para paliação da obstrução biliar maligna irressecável. Materiais e Métodos: Nós investigamos, retrospectivamente, 99 pacientes com obstrução maligna irressecável tratada com implante percutâneo de stent metálico autoexpansível em nossa instituição, de março de 2007 até janeiro de 2010. Os níveis séricos de bilirrubina e enzimas hepáticas foram medidos antes e 30 dias após o implante do stent. Para os procedimentos em que foi utilizado o stent de elgiloy ou o stent de nitinol, as taxas de oclusão dos stents e as taxas de sobrevida dos pacientes foram calculadas pela análise de Kaplan-Meyer. Resultados: Os pacientes mostraram melhora clínica após o implante dos stents, sem diferença entre os dois grupos. As taxas de sobrevida livre de oclusão foram 67% aos 30 dias, 37% aos 90 dias, 25% aos 180 dias e 10% aos 360 dias para ambos os grupos, sem diferença significativa em relação ao tipo de stent. Conclusão: Os dois stents mostraram eficácias comparáveis no tratamento da doença biliar maligna irressecável, com bons resultados clínicos.

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In the last module of this consensus, controversial topics were discussed. Management of the disease after progression during first line chemotherapy was the first discussion. Next, the benefits of liver resection in the presence of extra-hepatic disease were debated, as soon as, the best sequence of treatment. Conversion chemotherapy in the presence of unresectable liver disease was also discussed in this module. Lastly, the approach to the unresectable disease was also discussed, focusing in the best chemotherapy regimens and hole of chemo-embolization.

Neste último módulo do consenso, abordou-se alguns temas controversos. O primeiro tópico discutido foi o manejo da doença após progressão na primeira linha de quimioterapia, com foco em se ainda haveria indicação cirúrgica neste cenário. A seguir, o painel debruçou-se sobre as situações de ressecção da doença hepática na presença de doença extra-hepática, assim como, qual a melhor sequência de tratamento. O tratamento de conversão para doença inicialmente irressecável também foi abordado neste módulo, incluindo as importantes definições de quando se pode esperar que a doença se torne ressecável e quais esquemas terapêuticos seriam mais efetivos à luz dos conhecimentos atuais sobre a biologia tumoral e taxas de resposta objetiva. Por último, o tratamento da doença não passível de ressecção foi discutida, focando-se nos melhores esquemas a serem empregados e seu sequenciamento, bem como o papel da quimioembolização no manejo destes pacientes.

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ABSTRACT In the last module of this consensus, controversial topics were discussed. Management of the disease after progression during first line chemotherapy was the first discussion. Next, the benefits of liver resection in the presence of extra-hepatic disease were debated, as soon as, the best sequence of treatment. Conversion chemotherapy in the presence of unresectable liver disease was also discussed in this module. Lastly, the approach to the unresectable disease was also discussed, focusing in the best chemotherapy regimens and hole of chemo-embolization.

RESUMO Neste último módulo do consenso, abordou-se alguns temas controversos. O primeiro tópico discutido foi o manejo da doença após progressão na primeira linha de quimioterapia, com foco em se ainda haveria indicação cirúrgica neste cenário. A seguir, o painel debruçou-se sobre as situações de ressecção da doença hepática na presença de doença extra-hepática, assim como, qual a melhor sequência de tratamento. O tratamento de conversão para doença inicialmente irressecável também foi abordado neste módulo, incluindo as importantes definições de quando se pode esperar que a doença se torne ressecável e quais esquemas terapêuticos seriam mais efetivos à luz dos conhecimentos atuais sobre a biologia tumoral e taxas de resposta objetiva. Por último, o tratamento da doença não passível de ressecção foi discutida, focando-se nos melhores esquemas a serem empregados e seu sequenciamento, bem como o papel da quimioembolização no manejo destes pacientes.

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OBJECTIVES: To evaluate the preliminary results obtained using diffusion-weighted magnetic resonance imaging and the apparent diffusion coefficient for planning computed tomography-guided biopsies of selected mediastinal lesions. METHODS: Eight patients with mediastinal lesions suspicious for malignancy were referred for computed tomography-guided biopsy. Diffusion-weighted magnetic resonance imaging and apparent diffusion coefficient measurement were performed to assist in biopsy planning with diffusion/computed tomography fused images. We selected mediastinal lesions that could provide discordant diagnoses depending on the biopsy site, including large heterogeneous masses, lesions associated with lung atelectasis or consolidation, lesions involving large mediastinal vessels and lesions for which the results of biopsy using other methods and histopathological examination were divergent from the clinical and radiological suspicion. RESULTS: In all cases, the biopsy needle was successfully directed to areas of higher signal intensity on diffusion-weighted sequences and the lowest apparent diffusion coefficient within the lesion (mean, 0.8 [range, 0.6-1.1]×10-3 mm2/s), suggesting high cellularity. All biopsies provided adequate material for specific histopathological diagnoses of four lymphomas, two sarcomas and two thymomas. CONCLUSION: Functional imaging tools, such as diffusion-weighted imaging and the apparent diffusion coefficient, are promising for implementation in noninvasive and imaging-guided procedures. However, additional studies are needed to confirm that mediastinal biopsy can be improved with these techniques.

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OBJECTIVES: To evaluate the preliminary results obtained using diffusion-weighted magnetic resonance imaging and the apparent diffusion coefficient for planning computed tomography-guided biopsies of selected mediastinal lesions. METHODS: Eight patients with mediastinal lesions suspicious for malignancy were referred for computed tomography-guided biopsy. Diffusion-weighted magnetic resonance imaging and apparent diffusion coefficient measurement were performed to assist in biopsy planning with diffusion/computed tomography fused images. We selected mediastinal lesions that could provide discordant diagnoses depending on the biopsy site, including large heterogeneous masses, lesions associated with lung atelectasis or consolidation, lesions involving large mediastinal vessels and lesions for which the results of biopsy using other methods and histopathological examination were divergent from the clinical and radiological suspicion. RESULTS: In all cases, the biopsy needle was successfully directed to areas of higher signal intensity on diffusion-weighted sequences and the lowest apparent diffusion coefficient within the lesion (mean, 0.8 [range, 0.6-1.1]×10-3 mm2/s), suggesting high cellularity. All biopsies provided adequate material for specific histopathological diagnoses of four lymphomas, two sarcomas and two thymomas. CONCLUSION: Functional imaging tools, such as diffusion-weighted imaging and the apparent diffusion coefficient, are promising for implementation in noninvasive and imaging-guided procedures. However, additional studies are needed to confirm that mediastinal biopsy can be improved with these techniques. .

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Objetivo: Determinar taxas de definição diagnóstica e complicações da biópsia percutânea guiada por tomografia computadorizada (TC) de lesões ósseas suspeitas de malignidade. Materiais e Métodos: Estudo retrospectivo que incluiu 186 casos de biópsia percutânea guiada por TC de lesões ósseas no período de janeiro de 2010 a dezembro de 2012. Todas as amostras foram obtidas usando agulhas de 8 a 10 gauge. Foram coletados dados demográficos, história de neoplasia maligna prévia, dados relacionados à lesão, ao procedimento e ao resultado histológico. Resultados: A maioria dos pacientes era do sexo feminino (57%) e a idade média foi 53,0 ± 16,4 anos. Em 139 casos (74,6%) a suspeita diagnóstica era metástase e os tumores primários mais comuns foram de mama (32,1%) e próstata (11,8%). Os ossos mais envolvidos foram coluna vertebral (36,0%), bacia (32,8%) e ossos longos (18,3%). Houve complicações em apenas três pacientes (1,6%), incluindo uma fratura, um caso de parestesia com comprometimento funcional e uma quebra da agulha necessitando remoção cirúrgica. Amostras de 183 lesões (98,4%) foram consideradas adequadas para diagnóstico. Resultados malignos foram mais frequentes nos pacientes com suspeita de lesão secundária e história de neoplasia maligna conhecida (p < 0,001) e nos procedimentos orientados pela PET/CT (p = 0,011). Conclusão: A biópsia percutânea guiada por TC é segura e eficaz no diagnóstico de lesões ósseas suspeitas. .

Objective: To determine the rates of diagnostic success and complications of computed tomography (CT)-guided percutaneous biopsy of bone lesions suspected for malignancy. Materials and Methods: Retrospective study including 186 cases of CT-guided percutaneous biopsies of bone lesions in the period from January, 2010 to December, 2012. All the specimens were obtained with 8-10 gauge needles. The following data were collected: demographics, previous history of malignancy, data related to the lesion, to the procedure, and to histological results. Results: Most patients were women (57%), and the mean age was 53.0 ± 16.4 years. In 139 cases (74.6%), there was diagnostic suspicion of metastasis and the most common primary tumors were breast (32.1%) and prostate (11.8%). The bones most commonly involved were spine (36.0%), hip (32.8%) and long bones (18.3%). Complications occurred in only three cases (1.6%) including bone fracture, paresthesia with functional impairment, and needle breakage requiring surgical removal. The specimens collected from 183 lesions (98.4%) were considered appropriate for diagnosis. Malignant results were more frequently found in patients who had a suspected secondary lesion and history of known malignancy (p < 0.001), and in patients who underwent PET/CT-guided procedures (p = 0.011). Conclusion: CT-guided percutaneous biopsy is a safe and effective procedure for the diagnosis of suspicious bone lesions. .