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Interventional radiology has been constantly developing in terms of the techniques, materials, and methods of intervention. It interacts with all areas of medicine, always with the ultimate goal of ensuring the well-being of patients. Advances in imaging techniques, especially in the last two decades, have led to a paradigm shift in the field of urological imaging interventions. Many urologic diseases that were previously treated only surgically can now be effectively managed using minimally invasive image-guided techniques, often with shorter hospital stays and requiring only local anesthesia or conscious sedation. Resumo A radiologia intervencionista vem se desenvolvendo constantemente por meio de técnicas, materiais e métodos de intervenção. Interage com todas as áreas da medicina, sempre visando, como objetivo final, o bem-estar dos pacientes. Os avanços das técnicas de imagem, especialmente nas últimas duas décadas, levaram a uma mudança de paradigma no campo das intervenções guiadas por imagens na urologia. Muitas doenças urológicas que eram tratadas somente cirurgicamente, podem agora ser manejadas efetivamente usando técnicas minimamente invasivas guiadas por imagem, muitas vezes com redução do tempo de internação e utilizando apenas anestesia local ou sedação consciente.

Objective: To identify the main hemorrhagic complications after percutaneous nephrolithotomy, as well as the results obtained with transcatheter arterial embolization (TAE) at an interventional radiology center. Materials and Methods: This was a retrospective analysis of patients undergoing TAE for the treatment of hemorrhagic complications after percutaneous nephrolithotomy. All patients underwent computed tomography angiography (CTA). Results: We evaluated a total of nine patients. At emergency department readmission, the most common symptom was macroscopic hematuria, which was seen in five patients. Three patients had an isolated pseudoaneurysm, two had a pseudoaneurysm together with active bleeding (perirenal hematoma), and one had a pseudoaneurysm together with arteriocalyceal fistula. Arteriovenous fistula was diagnosed in three patients and was not seen in combination with other vascular lesions. We did not identify arteriocalyceal fistula in isolation. Five patients underwent TAE with 6 × 15 mm and 6 × 20 mm microcoils. Four patients underwent TAE with n-butyl-2-cyanoacrylate and ethiodized oil. Follow-up CTAs revealed no complications. Conclusion: Because of its high diagnostic accuracy, CTA provides the interventional radiologist with valuable data for individualized therapeutic planning. The TAE procedure is safe and effective. It can therefore be used as a first-line treatment for hemorrhagic complications resulting from percutaneous renal procedures. Resumo Objetivo: Demonstrar as principais complicações hemorrágicas após nefrolitotripsia percutânea, bem como os resultados após o tratamento por embolização arterial transcateter (EAT) em um centro de radiologia intervencionista. Materiais e Métodos: Coleta e análise de dados retrospectivos de pacientes submetidos a EAT por complicações hemorrágicas após nefrolitotripsia percutânea. Resultados: O sintoma mais comum foi hematúria macroscópica, presente em cinco pacientes no momento da readmissão ao pronto-socorro, e nestes pacientes identificamos três pseudoaneurismas isolados, dois casos de combinação de pseudoaneurisma e sangramento ativo (hematoma perirrenal) e um caso de associação de pseudoaneurisma e fístula arteriocalicinal. Fístula arteriovenosa foi diagnosticada em três pacientes, não sendo observada em associação com outras lesões vasculares. Não identificamos fístula arteriocalicinal isolada, somente associada a pseudoaneurisma. Cinco pacientes foram submetidos a embolização por micromolas 6 × 15 mm e 6 × 20 mm. Quatro pacientes foram submetidos a embolização por Histoacryl e Lipiodol. Não observamos complicações pela angiotomografia computadorizada de controle. Conclusão: A angiotomografia computadorizada apresenta alta acurácia diagnóstica e guarnece o radiologista intervencionista de dados para um planejamento terapêutico individualizado. EAT é um procedimento seguro e eficaz e pode ser utilizado como primeira linha para o tratamento de complicações hemorrágicas resultantes de procedimentos percutâneos renais.

To describe a novel technique of percutaneous transhepatic (PTH) placement of a plastic biliary stent (PBS), report the feasibility and safety of the technique, and present the preliminary results of a pilot study that included 32 patients with symptomatic obstructive jaundice (SOJ) treated with the technique. This was a prospective, single-arm, single-center, pilot study of a cohort of patients with the diagnosis of benign or malignant obstructive jaundice that underwent PTH placement of a PBS to relieve the obstruction. Thirty-two patients were included, 16 men and 16 women (age range, 35–88 years). There were 26 malignant and six benign lesions. Cholangiocarcinoma was the most common tumor (n=13, 40.6%), followed by pancreatic adenocarcinoma (n=6, 18.75%) and metastasis (n=5, 15.6%). A total of 35 PBSs were placed in 32 procedures. The bile duct was accessed and drained to the right side in 18 cases, to the left side in 14 cases, and bilaterally in three cases. Technical success was achieved in 100% and clinical success in 93.7% of cases. Using a modified Bismuth-Cortelle classification system, type I was observed in nine patients, type II in nine patients, type III in six patients, and type IV in eight patients. The mean follow-up was 426.1 days for the total sample, and 349.4 days for patients with malignancy. Two complications were observed: transient hemobilia and cholangitis. PTH placement of a PBS in patients with SOJ is feasible, safe, and effective.

Background Although changes in uterine contractility pattern after uterine fibroid embolization (UFE) has already been assessed by cine magnetic resonance imaging (MRI), their impact on quality of life outcomes has not been evaluated. The purpose of this study was to evaluate the impact of uterine contractility on the quality of life of women undergoing UFE measured by the Uterine Fibroid Symptom and Quality of Life questionnaire (UFS-QOL). Results A total of 26 patients were included. MRI scans were acquired 30–7 days before and 6 months after UFE for all patients. The UFS-QOL was applied in person on first MRI exam day and 1 year after UFE and the outcomes were analyzed according to the groups of evolution pattern of uterine contractility: Group A: Unchanged Uterine Contractility Pattern, 38%; Group B: Favorable Modified Uterine Contractility Pattern, 50%; and Group C: Loss of Uterine Contractility, 11%. All UFE patients presented a reduction in the mean score for symptoms and increase in mean scores on quality of life. All patients in this cohort presented a reduction in mean symptom score and increase in the mean score of quality of life subscales. Group A had more relevant complaints regarding their sense of self-confidence; Group B presented worse sexual function scores before UFE, which improved after UFE compared to Group A. Conclusions Significant improvement in symptoms, quality of life, and uterine contractility was observed after UFE in women of reproductive age with symptomatic fibroids. Functional uterine contractility seems to have a positive impact on quality of life and sexual function in this population. Level of evidence Level 3, Non-randomized controlled cohort/follow-up study.

Background. Hepatocellular carcinoma (HCC) is the most common malignancy that develops in cirrhotic livers. Its clinical and epidemiological characteristics and mortality rates vary according to geographical region. The objective of this study was to evaluate the clinical profile, epidemiological characteristics, laboratory parameters, treatment and survival of patients with HCC. Material and methods. methods. methods. Patients with HCC seen between 2000 and 2012 were studied. The Kaplan-Meier method was used for survival analysis according to variables in question. Results. Results. Results. The study included 247 patients with a mean age of 60 ± 10 years. There was a predominance of males (74%). The main etiologies of HCC were HCV infection (55%), excessive alcohol consumption (12%), and HBV infection (8%). Liver cirrhosis was present in 92% of cases. The mean tumor number and diameter were 2 and 5 cm, respectively. Patients meeting the Milan criteria corresponded to 43% of the sample. Liver transplantation was performed in 22.4% of patients of the Milan subset and in 10% of the whole sample. The overall mean survival was 60 months, with a 1-, 3- and 5-year survival probability of 74%, 40% and 29%, respectively. Lower survival was observed among patients with alcoholic etiology. Survival was higher among patients submitted to liver transplantation (P < 0.001), TACE (P < 0.001), or any kind of treatment (P < 0.001). However, no difference was found for surgical resection (P = 0.1) or sorafenib (P = 0.1). Conclusion. Conclusion. Conclusion. Patients with HCC were mainly older men diagnosed at an advanced stage. Treatment was associated with better overall survival, but few patients survived to be treated

Uveal melanoma is the most common adult primary intraocular cancer. Although liver metastasis is common to the natural history of the disease, metastasis to the fellow eye is extremely rare. Here we report the case of a 59-year-old man with choroidal melanoma in his right eye who underwent enucleation at a different center. The patient was referred to our service 21 months postoperatively, complaining of decreased vision. He was found to have a new pigmented choroidal tumor in his left eye associated with liver disease. Ocular ultrasonography and liver biopsy with histopathological and immunohistochemical analysis were performed and confirmed the diagnosis. Few similar cases have been described in the literature. The differential diagnosis included primary bilateral choroidal melanoma and metastatic choroidal tumor from a primary skin melanoma.

Objective To evaluate improvement in quality of life, reduction of uterine volume, and the correlation between these two variables after uterine fibroid embolization. Methods Data on quality of life before and after uterine fibroid embolization were collected from 60 patients using the Uterine Fibroid Symptom – Quality of Life questionnaire. In 40 of these patients, uterine volume information on magnetic resonance imaging examinations performed before and after uterine fibroid embolization was collected, and compared using the nonparametric Wilcoxon test for paired data. Correlation between quality of life and uterine volume before and after procedure was measured using Spearman’s correlation coefficient. Results There was significant improvement in quality of life after uterine fibroid embolization on Uterine Fibroid Symptom – Quality of Life questionnaire, in both subscales scores and the total score. There was a significant median reduction of -37.4% after uterine fibroid embolization, but no correlations between uterine volume and quality of life scores were found before or after embolization. Conclusion Uterine embolization is an alternative to treat uterine fibroids, resulting in relief of symptoms and better quality of life. Although reduction in uterine volume plays an important role in the evaluation of therapeutic success, it does not necessarily have a definitive correlation with relief of symptoms.

To assess uterine contractility using ultrafast magnetic resonance imaging (cine MRI) before and after uterine fibroid embolization (UFE). This is a prospective study of uterine contractility in 26 patients (age 30–41 years) undergoing UFE for symptomatic uterine fibroids. Cine MRI was performed before and 6 months after UFE. Two radiologists evaluated uterine contractility and classified it as absent, ordered, or disordered. Patients were then grouped into three distinct patterns of progression: unchanged contractility (group A), modified contractility (B), and loss of contractility (C). These findings were then confronted with factors that might have interfered with uterine contractility pattern (uterine volume, location of dominant fibroid, fibroid/myometrium index, and fibroid necrosis pattern). Of the 26 patients, 8 (30.7%) had no contractility before the procedure, while 18 (69.2%) exhibited some form of contractility (11 [61%] ordered, 7 [39%] disordered). All 8 patients who had no contractility at baseline exhibited contractility after UFE (5 ordered, 3 disordered). Of the 11 who had ordered contractility at baseline, 9 remained ordered and 2 lost contractility after UFE. Of the 7 with disordered contractility at baseline, 1 remained disordered, 5 progressed to ordered contractility, and 1 lost contractility. Overall, 10 patients (38%) had no change in contractility after UFE (group A), 13 (50%) had a positive change (group B), and 3 (11%) lost contractility (group C). The potential interference factors assessed had no statistically significant effect in any group. In women of reproductive age with symptomatic fibroids, uterine contractility improved significantly after UFE. Level 3—non-randomized controlled cohort/follow-up study.

Background and aim There are several prognostic systems that address different aspects of the patient and the tumour and can guide the management of patients with hepatocellular carcinoma (HCC). This study aimed to evaluate and compare the eight staging systems for a group of patients in a public service in Brazil. Methods Patients with HCC were retrospectively analysed between 2000 and 2012. The prognostic systems Okuda, The Cancer of the Liver Italian Program (CLIP), the Chinese University Prognostic Index (CUPI), Groupe d'Etude et de Traitement du Carcinome Hepatocellulaire (GRETCH), the modified TNM-based Japan Integrated Score (JIS) combined with alpha-fetoprotein and Child-Turcotte-Pugh (CTP), the TNM system, and the Barcelona Clinic Liver Cancer Classification (BCLC) were applied to these patients and compared through model fit measurements, likelihood scores, and the Akaike Information Criterion (AIC). Results A total of 247 patients were studied. The average survival time was 60 months. The TNM, Okuda, CLIP, GRETCH, modified JIS, and BCLC systems were well correlated with one another and individually important to the prediction of survival among the patients studied. However, in the statistical analysis, the CUPI delivered the best predictive performance (AIC = 566 log-likelihood =-281,240). Conclusion Although the CUPI system was demonstrated to be the most appropriate HCC staging system for the studied population, the choice of an ideal system is a controversial subject, andfuture studies with larger numbers of patients are necessary for the validation of the CUPI system as the method of choice for other populations. Fed Univ Sao Paulo Unifesp, Hepatol Unit, Dept Gastroenterol, Sao Paulo, SP, Brazil Fed Univ Sao Paulo Unifesp, Liver Transplant Unit, Dept Surg, Sao Paulo, SP, Brazil Fed Univ Sao Paulo Unifesp, Dept Pediat Surg, Sao Paulo, SP, Brazil Fed Univ Sao Paulo Unifesp, Dept Diagnost Radiol, Sao Paulo, SP, Brazil Fed Univ Sao Paulo Unifesp, Dept Diagnost Pathol, Sao Paulo, SP, Brazil Fed Univ Sao Paulo Unifesp, Hepatol Unit, Dept Gastroenterol, Sao Paulo, SP, Brazil Fed Univ Sao Paulo Unifesp, Liver Transplant Unit, Dept Surg, Sao Paulo, SP, Brazil Fed Univ Sao Paulo Unifesp, Dept Pediat Surg, Sao Paulo, SP, Brazil Fed Univ Sao Paulo Unifesp, Dept Diagnost Radiol, Sao Paulo, SP, Brazil Fed Univ Sao Paulo Unifesp, Dept Diagnost Pathol, Sao Paulo, SP, Brazil Web of Science

Purpose To evaluate clinical and laboratory findings in patients undergoing radiofrequency (RF) ablation for functioning adrenal adenomas. Materials and Methods Eleven adult patients, nine with Conn syndrome and two with Cushing syndrome, underwent percutaneous computed tomography–guided RF ablation for benign adrenal neoplasms. Systolic, diastolic, and mean blood pressure and the number of classes of antihypertensive drugs used by each patient were analyzed before and 1, 4, and 12 weeks after the procedure. Serum hormone levels were analyzed within 30 days before and 12 weeks after the procedure. Results Of the nine patients with Conn syndrome, eight showed normal serum aldosterone levels after the procedure and one patient had a nodule located very close to the inferior vena cava, resulting in incomplete ablation. The two patients with Cushing syndrome had normal serum and salivary cortisol levels after the procedure. Mean aldosterone concentration at baseline was 63.3 ng/dL ± 28.0 and decreased to 13.3 ng/dL ± 13.5 at 12 weeks postoperatively ( P = .008). Systolic, diastolic, and mean blood pressures decreased significantly in the first week after the procedure ( P Conclusions In patients with Conn syndrome or Cushing syndrome, percutaneous RF ablation of functioning adrenal adenomas may result in normalization of hormone secretion, improvement in blood pressure, and reduced need for antihypertensive drugs.

The present article is aimed at reporting the author's experience with transcatheter arterial embolization using a lipiodol-ethanol mixture in three cases of unresectable symptomatic giant hepatic hemangiomas.The cases of three patients with giant unresectable symptomatic hepatic hemangiomas embolized in the period 2009-2010 were retrospectively reviewed. In all the cases, transarterial embolization was performed with an ethanol-lipiodol mixture.Symptoms regression and quality of life improvement were observed in all the cases. No complications were observed and all the patients were discharged within 12 hours after the procedure.Transcatheter arterial embolization using ethanol mixed with lipiodol was a safe and effective treatment for symptomatic giant hepatic hemangiomas in this small series of patients.Este estudo teve como objetivo relatar a experiência dos autores de embolização arterial transcateter com o uso de uma mistura de lipiodol e etanol em três casos de hemangiomas hepáticos gigantes sintomáticos e não ressecáveis.Três hemangiomas hepáticos gigantes sintomáticos e não ressecáveis em três pacientes foram embolizados com o uso de uma mistura transarterial de etanol e lipiodol.A regressão dos sintomas e a melhora na qualidade de vida foram observadas em todos os casos. Nenhuma complicação foi encontrada e todos os pacientes receberam alta em até 12 horas após o procedimento.O etanol misturado com o lipiodol foi um tratamento eficaz e seguro para hemangiomas hepáticos gigantes sintomáticos nesta pequena série de pacientes.

Background: Management of uterine myomas aims at improving symptoms that can be a problem and interfere in the patient’s quality of life. Less invasive approaches, such as uterine artery embolization (UAE), for selected patients is supposed to be a safer choice. Methods: Thirty-one women (mean age 38.5 ± 5.9) with symptomatic uterine myomas underwent UAE. All them scored 0 (mildest) to 10 (worst) for discomforting symptoms (abdominal pain (cramping) during and out of menstrual periods; bleeding during and out of menstrual periods; discomforting abdominal swelling; pain during sexual intercourse; general discomfort in diary activities and in social activities) before and 90 days after UAE. Results: Mean scores before and 90 days after UAE were significantly different for all symptoms, except for pain in sexual intercourse. Scores for bleeding out of menstrual periods increased after UAE, and decreased for all the other symptoms. Total scores before management (43.8 ± 25.4) decreased significantly (p

The objective of this study was to establish the suitability of the apparent diffusion coefficient (ADC) as a parameter for evaluating early treatment response after percutaneous ablation of functional adrenal adenomas.Seventeen adult patients with functioning adrenal adenomas underwent radiofrequency ablation. Serum hormone levels were analyzed before and up to 6 months after ablation. MRI findings (nodule size in cm, signal intensity index, ADC maps, and nodule-to-muscle ADC ratio) were analyzed before and up to 30 days after ablation. A consensus review of all scans was performed by two attending abdominal imaging radiologists. The procedure was considered successful if serum hormone levels normalized and no contrast enhancement of the adrenal lesion was seen on follow-up MRI.Of 17 patients who underwent radiofrequency ablation, complete response was achieved in 16 patients with partial response in one patient. Of the four parameters of interest, only ADC maps and nodule-to-muscle ADC ratio showed statistically significant differences (p0.05).This prospective study suggests that apparent diffusion coefficient values may help radiologists monitor early treatment response after CT-guided radiofrequency ablation of functioning adrenal adenomas.

Transluminal balloon angioplasty is a good choice for the treatment of lower limb arterial occlusion. Although there are some guidelines addressing its indications, some situations are so unusual that there is no consensus on their management. The presence of a persistent sciatic artery is a rare congenital anomaly of the circulatory system and may be associated with early atheromatous degeneration and occlusion. The authors describe the case of an 81-year-old woman that presented with a history of rest pain, atrophic lesion and no distal pulses. Angiogram depicted a persistent sciatic artery with segmental occlusion and distal disease. The therapeutic option was balloon angioplasty of the occluded segment, with technical and clinical success at mid-term follow-up.

Development of biliary strictures after liver transplantation is not uncommon, and minimally invasive procedures are the first-line treatment of choice in most centers. Hemobilia is an infrequent, usually self-limited complication related to the initial biliary access procedure. Massive hemobilia with severe hemodynamic instability is a rare event, particularly as a delayed complication. The difficulty of obtaining surgical access makes management of this condition highly challenging. Endovascular embolization may represent an important treatment option in this setting.

We report a case of a 51-year-old Caucasian man with progressive heart failure and multiple lytic lesions in the skull and long bones. The diagnosis of multiple myeloma and cardiac involvement by secondary amyloidosis was made, but the patient died despite treatment, and the diagnosis was confirmed at autopsy. Cardiac amyloidosis is clinically silent and when the symptoms appear, median survival is less than 1 year. The diagnosis of amyloidosis should be considered in any patient with multiple myeloma and heart failure, and the magnetic resonance imaging (MRI) can help to make this diagnosis.

PURPOSE: To evaluate the accuracy and reproducibility of magnetic resonance cholangiopancreatography (MRCP) in the detection of biliary complications in liver transplanted patients. METHODS: A study was conducted, with blinded review of 28 MRCP exams of 24 patients submitted to liver transplantation. The images were reviewed by two independent observers, at two different moments, regarding the degree of biliary tree visualization and the presence or absence of biliary complications. The MRCP results were compared, when negative, to at least 3 months of clinical and biochemical follow-up, and when positive, to the findings at surgery or endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: The degree of intrahepatic biliary tree visualization was considered good or excellent in 78.6% and 82.1% of the exams by the two observers and visualization of the donor duct, recipient duct and biliary anastomosis was considered good or excellent in 100% of the exams, by both observers. Six biliary complications were detected (21.4%), all of them anastomotic strictures. Intra and interobserver agreement were substantial or almost perfect (kappa k values of 0.611 to 0.804) for the visualization of the biliary tree and almost perfect (k values of 0.900 to 1.000) for the detection of biliary complications. MRCP achieved 100% sensitivity, 95.45% specificity, 85.7% positive predictive value and 100% negative predictive value for the detection of biliary complications. CONCLUSIONS: MRCP is an accurate examination for the detection of biliary complications after orthotopic liver transplantation and it is a highly reproducible method in the evaluation of the biliary tree of liver transplanted patients. OBJETIVO: Medir a acurácia e reprodutibilidade da colangiopancreatografia por ressonância magnética (CPRM) na avaliação da visibilização de complicações biliares em pacientes submetidos a transplantes hepáticos ortotópicos. MÉTODOS: Realizado estudo retrospectivo de 28 exames de CPRM de 24 pacientes submetidos a transplantes hepáticos. Os exames foram interpretados por dois observadores independentes, em dois momentos distintos, quanto ao grau de visibilização das estruturas estudadas e quanto à presença ou ausência de alterações nas vias biliares. Os resultados da CPRM foram comparados, nos casos de CPRM negativa, à evolução clínico-laboratorial por pelo menos 3 meses e, nos casos de CPRM alterada, aos achados de colangiopancreatografia retrógrada endoscópica (CPRE) e cirurgia, quando indicados. RESULTADOS: A visibilização das vias biliares intra-hepáticas foi considerada boa ou excelente em 78,6% e 82,1% dos exames pelos dois observadores. A visibilização da via biliar extra-hepática do doador e do receptor, bem como da anastomose biliar, foi considerada boa ou excelente em 100% dos casos por ambos os observadores. Foram detectadas seis complicações biliares (21,4% dos casos), todas elas estenoses anastomóticas. A concordância intra e intra-observador foi substancial ou quase perfeita (índices de kappa- k de 0,611 a 0,804) para a visualização das estruturas estudadas e quase perfeita (k de 0,900 a 1,000) para a detecção das complicações biliares. A CPRM apresentou sensibilidade de 100%, especificidade de 95,45%, valor preditivo positivo de 85,7% e valor preditivo negativo de 100% para a detecção de complicações biliares. CONCLUSÕES: A colangiopancreatografia por ressonância magnética (CPRM) é um exame acurado para a detecção de complicações biliares em pacientes submetidos a transplantes hepáticos ortotópicos por CPRM. Este exame configura-se como um método eficiente e altamente reprodutível para detecção de complicações biliares pós-transplantes hepáticos ortotópicos.

Síndrome da aorta média (SAM) é uma condição clínica caracterizada por estenose segmentar ou difusa da aorta, hipertensão arterial e claudicação de membros inferiores. A principal causa da SAM é a arterite de Takayasu. A estenose segmentar pode estar localizada na aorta suprarrenal, renal ou infrarrenal e com alta propensão de lesões estenóticas concomitantes das artérias renais e viscerais. A gravidade da hipertensão arterial é a principal indicação para o tratmento. A técnica endovascular para o tratamento da síndrome da aorta média tem bons resultados e é a menos invasiva. No presente artigo, é descrito o tratamento com sucesso de uma estenose da aorta toracoabdominal com recanalização da artéria mesentérica superior através de angioplastia em uma mulher de 34 anos portadora de arterite de Takayasu e hipertensão arterial grave.

Purpose: The aim of our study was to evaluate the role of MR cholangiography (MRC) in the diagnosis of biliary complications after orthotopic liver transplantation (OLT). Method: Twenty-one liver transplantation patients underwent MRC using a T2-weighted sequence (HASTE). Diagnostic confirmation was obtained with endoscopic retrograde cholangiography (ERCP) (n=11), surgery (n=3), or clinical and laboratory follow-up of at least 1 year (n=8). Results: In 13 patients, no abnormality of the biliary tract was detected by MRC. In 8 patients, anastomotic strictures were diagnosed, 7 of which were confirmed at surgery or ERCP. One patient with normal MRC and abnormal liver function tests was found to have a stricture at ERCP. All patients with normal MRC and liver function tests had 1 year of uneventful follow- up and were considered true-negative cases. We found that MRC had 87.5% sensitivity, 92.3% specificity, 87.5% positive predictive value, 92.3% negative predictive value and 90.4% accuracy in the diagnosis of biliary complications. Conclusion: MRC is a valuable examination for detecting biliary complications after OLT and provides useful information for planning interventional procedures.

The advent of interventional radiology enabled remarkable advances in diagnosis and treatment of several situations in obstetrics and gynecology. In the field of obstetrics, these advances include temporary occlusion of the iliac arteries to the management of placenta accreta and/or prior, arteriovenous fistulas after embolization of uterine curettage and management of ectopic uterine and extra-uterine pregnancies. The non-tubal ectopic pregnancy, either cervical, abdominal, ovarian or in a cesarean scar, often represents major therapeutic challenge, especially when exists a desire to maintain fertility. Despite the systemic methotrexate therapy and surgical resection of the ectopic gestational sac be the most used therapeutic options, the interventionist approach of non-tubal ectopic pregnancies, direct injection of methotrexate in the gestational sac and intra-arterial chemoembolization of uterine arteries constitute in the currently literature viable, safe, effective modalities with low morbidity, shorter hospital stay, and rapid clinical recovery. Because of little variety of materials used, and the increase in training of specialists in the area, the radiological intervention as a treatment option in ectopic pregnancies is financially viable and present considerable accessibility in the world and at most of Brazilian medical centers. O advento da radiologia intervencionista tornou possível avanços notáveis no diagnóstico e no tratamento de diversas situações, na área de ginecologia e obstetrícia. No campo da obstetrícia, esses avanços incluem oclusão temporária das artérias hipogástricas para o manejo de placenta acreta e/ou prévia, embolização de fístulas arteriovenosas após curetagem uterina e manejo de prenhezes ectópicas uterinas e extrauterinas. A gravidez ectópica não tubária, seja cervical, abdominal, ovariana ou na cicatriz de cesárea, muitas vezes representa grande desafio terapêutico, principalmente quando há desejo de manutenção da fertilidade. As opções terapêuticas mais utilizadas para o tratamento de prenhez ectópica não tubária, são: terapia sistêmica com metotrexato e ressecção cirúrgica do saco gestacional ectópico; porém a abordagem intervencionista com injeção direta de metotrexato no saco gestacional ou quimiembolização intra-arterial das artérias uterinas, apresentam-se na literatura recente, como modalidades terapêuticas viáveis, seguras, eficazes, com baixa morbidade, menor tempo de internação e rápida recuperação clínica. Devido ao diminuto arsenal de materiais utilizados e à crescente formação de especialistas na área, a intervenção radiológica, como opção de tratamento nas prenhezes ectópicas, é financeiramente viável e apresenta acessibilidade considerável no mundo e na maioria do centros médicos brasileiros.

Cesarean scar pregnancy is a rare form of ectopic pregnancy. It is associated with many complications, including a high risk of massive bleeding and hysterectomy under unfavorable conditions. Conservative treatment with systemic methotrexate (MTX) has been used preferentially with the aim of allowing the patient to have a reproductive future. However, cases of complex ectopic masses in a cesarean scar with guarded prognosis demand techniques that are more effective, such as uterine artery embolization (UAE) in association with intra-arterial MTX infusion. We describe the case of a 35-year-old patient in the 8th week of pregnancy who was referred to us because of genital bleeding and suspected ectopic pregnancy in the cesarean scar. After confirmation of the diagnosis, an initial attempt at systemic treatment with MTX was made. This was abandoned due to the elevation of the hepatic transaminase level. In addition, because of the complexity of the mass and the patient’s desire to preserve her reproductive capacity, it was decided to perform UAE with local MTX infusion. The procedure was performed successfully and the patient’s fertility was preserved.

The conventional treatment of functioning adrenal adenomas is laparoscopic resection. Since the 1990s, radiofrequency ablation has been increasingly applied to the treatment of tumours of the liver, lungs and musculoskeletal system. However, the use of radiofrequency ablation to treat adrenal nodules is still an uncommon procedure, particularly in aldosterone-producing adenomas. We report the case of a 35-year-old male patient with resistant hypertension, hypokalaemia and aldosterone-producing adenoma in a single adrenal gland. The patient underwent CT-guided percutaneous radiofrequency ablation. Clinical, laboratory and MRI follow-up data indicated excellent response to treatment. This case report is the first in the literature to describe the use of CT-guided percutaneous radiofrequency ablation in the treatment of a functioning adrenal adenoma in a patient with a single adrenal gland.

Percutaneous ablation of functioning adrenal adenomas has been an alternative to videolaparoscopic treatment. This study aimed to evaluate the feasibility, safety and efficacy of radiofrequency ablation (RFA) in the treatment of functioning adrenal tumors using a computed tomography (CT)-guided percutaneous technique as demonstrated by our experience and the literature. Eleven adult patients (mean age 46 years) with a diagnosis of functioning adrenal adenoma underwent CT-guided RFA between October 2011 and August 2012. All RFA procedures were performed using a needle electrode with a single lateral filament and the RITA® 1500X radiofrequency generator. The RFA protocol consisted of two cycles of 5 min each with 1-min interval, with no additional ablation cycles. Contrast-enhanced CT scans were obtained and analyzed for immediate treatment success and possible complications. Maximum tumor dimension ranged from 1.2 to 3.4 cm. The mean procedure time was 74 min, and length of hospital stay ranged from 0.9 to 3.2 days (mean 1.8 days). One patient had residual pneumothorax and one patient had neuritis involving the T10 dermatome. Of 11 patients, 10 recovered from their condition. Only one patient remained with hyperaldosteronism, but with reduced anti-hypertensive medication. CT-guided percutaneous RFA was a safe and effective treatment for functioning adrenal adenomas, with short hospital length of stay and low complication rate.

Thyroid metastasis from hepatocellular carcinoma (HCC) is rare, and has poor prognosis. We report the case of a 62-year-old woman seen at our clinic because of the occurrence of a slightly painful abdominal mass. At that time, alpha-fetoprotein concentration was very high, reaching 49,831.7 ng/mL. Abdominal ultrasound showed a heterogeneous mass in segment IV of the liver, which was diagnosed as HCC upon MRI. The patient underwent surgical resection and histological analysis of the specimen confirmed HCC. Metastases to the thyroid were detected 17 months after liver resection. Although the presence of metastases indicates advanced disease, thyroidectomy was performed, since no other distant metastases were detected. In fact, the patient is doing well 3 years after thyroidectomy and regular imaging exams showed no tumor recurrence. Current alpha-fetoprotein concentration is 8 ng/mL. In conclusion, thyroid metastasis from HCC is uncommon and short-term survival is expected. However, surgical resection should be encouraged, especially in the case of solitary metastases.

Purpose. To assess glutamine/glutamate (Glx) and lactate (Lac) metabolism using proton magnetic resonance spectroscopic imaging (1H-MRS) in order to differentiate between adrenal gland nodules and masses (adenomas, pheochromocytomas, carcinomas, and metastases). Materials and Methods. Institutional review board approval and informed consent were obtained. A total of 130 patients (47 men) with 132 adrenal nodules/masses were prospectively assessed (54 +/- 14.8 years). A multivoxel system was used with a two-dimensional point-resolved spectroscopy/chemical-shift imaging sequence. Spectroscopic data were interpreted by visual inspection and peak amplitudes of lipids (Lip), choline (Cho), creatine (Cr), Lac, and Glx. Lac/Cr and Glx/Cr were calculated. Glx/Cr was assessed in relation to lesion size. Results. Statistically significant differences were observed in Glx/Cr results between adenomas and pheochromocytomas (P < 0.05), however, with a low positive predictive value (PPV). Glx levels were directly proportional to lesion size in carcinomas. A cutoff point of 1.44 was established for the differentiation between carcinomas larger versus smaller than 4 cm, with 75% sensitivity, 100% specificity, 100% PPV, and 80% accuracy. Lac/Cr results showed no differences across lesions. A cutoff point of -6.5 for Lac/Cr was established for carcinoma diagnosis. Conclusion. Glx levels are directly proportional to lesion size in carcinomas. A cutoff point of -6.5 Lac/Cr differentiates carcinomas from noncarcinomas. Universidade Federal de São Paulo, Dept Diagnost Imaging, BR-04024002 São Paulo, Brazil Universidade Federal de São Paulo, Dept Endocrinol, BR-04024002 São Paulo, Brazil Universidade Federal de São Paulo, Dept Urol, BR-04024002 São Paulo, Brazil Universidade Federal de São Paulo, Dept Diagnost Imaging, BR-04024002 São Paulo, Brazil Universidade Federal de São Paulo, Dept Endocrinol, BR-04024002 São Paulo, Brazil Universidade Federal de São Paulo, Dept Urol, BR-04024002 São Paulo, Brazil Web of Science

FUNDAMENTO: Testes invasivos e não invasivos têm sido usados para identificar risco para Taquicardia Ventricular (TV) em pacientes com Cardiopatia Chagásica Crônica (CCC). Ressonância Magnética Cardíaca (RMC) pela técnica do Realce Tardio (RT) pode ser útil para selecionar pacientes com disfunção ventricular global ou segmentar, com alto grau de fibrose e maior risco para TV clínica. OBJETIVO: Melhorar a identificação de elementos preditivos de TV em pacientes com CCC. MÉTODO: Quarenta e um pacientes com CCC foram pesquisados, sendo 30 (72%) do sexo masculino, com média de idade de 55,1 ± 11,9 anos. Vinte e seis pacientes apresentavam histórico de TV (grupo TV), e 15 não apresentavam TV (grupo NTV). Todos os pacientes incluídos tinham RT e disfunção segmentar ventricular. Volume, porcentagem de comprometimento da espessura da parede ventricular em cada segmento, e distribuição de RT foi determinado em cada caso. RESULTADOS: Não houve diferença estatística em termos de volume de RT entre os dois grupos: grupo TV = 30,0 ± 16,2%; grupo NTV = 21,7 ± 15,7%; p = 0,118. A probabilidade de TV foi maior se duas ou mais áreas contíguas de fibrose transmural estivessem presentes, sendo um fator preditor de TV clínica (RR 4,1; p = 0,04). A concordância entre os observadores foi de 100% nesse critério (p < 0,001). CONCLUSÃO: A identificação de dois ou mais segmentos de RT transmural por RMC está associado com a ocorrência de TV clínica em pacientes com CCC. Portanto, a RMC melhora a estratificação de risco na população estudada. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0) BACKGROUND: Invasive and non-invasive tests have been used to identify the risk of ventricular tachycardia (VT) in patients with chronic Chagas' heart disease (CCHD). Cardiac magnetic resonance imaging (CMRI) using the delayed enhancement (DE) technique can be useful to select patients with global or segmentary ventricular dysfunction, with high degree of fibrosis and at higher risk for clinical VT. OBJECTIVE: To improve the identification of predictors of VT in patients with CCHD. METHOD: This study assessed 41 patients with CCHD [30 (72%) males; mean age, 55.1 ± 11.9 years]. Twenty-six patients had history of VT (VT group), and 15 had no VT (NVT group). All patients enrolled had DE and segmentary ventricular dysfunction. In each case, the following variables were determined: left ventricular volume; percentage of ventricular wall thickness impairment in each segment; and DE distribution. RESULTS: No statistical difference regarding the DE volume between both groups was observed: VT group = 30.0 ± 16.2%; NVT group = 21.7 ± 15.7%; p = 0.118. The probability of VT was greater in the presence of two or more contiguous transmural fibrosis areas, and that was a predictive factor of clinical VT (RR 4.1; p = 0,04). Agreement between observers was 100% regarding that criterion (p < 0.001). CONCLUSION: The identification of two or more segments of transmural DE by use of CMRI is associated with the occurrence of clinical VT in patients with CCHD. Thus, CMRI improved risk stratification in the population studied. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0)

Objective We evaluated the effect of diet therapy as exclusive treatment on insulin resistance, biochemical parameters of metabolic syndrome, and degree of hepatic steatosis in patients with non-alcoholic fatty liver disease. Methods Thirty-one patients with non-alcoholic fatty liver disease received a diet with a reduction of 500 to 1000 cal/d, containing 15% protein, 55% carbohydrates, and 30% fat, for 6 mo. At entry and 6 mo after dietary instructions, degrees of hepatic steatosis and visceral obesity were assessed by computed tomography; serum aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transferase, glucose, triacylglycerols, and high-density lipoprotein cholesterol were measured by automated methods. Body mass index, waist circumference, waist-to-hip ratio, and food intake (7-d diary) were also evaluated. At the end of follow-up, the patients were classified as adherent or non-adherent to treatment according to a weight loss of more or less than 5% of initial body weight, respectively. Results Seventeen patients were classified as adherent (group 1) and 14 as non-adherent (group 2). Group 2 only presented a significant reduction in body mass index and waist circumference. In contrast, in group 1, in addition to significant improvement of all anthropometric parameters, a significant reduction was observed in alanine aminotransferase and γ-glutamyl transferase levels, homeostasis model assessment for insulin resistance, visceral fat and tomographic liver density, together with an increase in serum high-density lipoprotein cholesterol levels. These patients presented a significant decrease in total energy intake and in total and saturated fats. Conclusion Nutritional intervention as exclusive treatment, with a loss of at least 5% of initial weight, is effective in the treatment of non-alcoholic fatty liver disease.

The purpose of this study was to report on clinical experience with and observations made during primary CT-guided percutaneous catheter drainage of acute necrotizing pancreatitis and to compare results among patients with sterile and those with infected necrosis.We reviewed clinical, radiologic, and bacteriologic data on 35 patients (23 men, 12 women; mean age, 50 years; range, 21-83 years) with acute necrotizing pancreatitis refractory to standard medical care who underwent CT-guided percutaneous catheter drainage with 12- to 22-French catheters. Experiences with two subgroups were compared. One group consisted of 22 patients, 10 with multisystem organ failure, who presented with sterile necrosis (median Atlanta score, 1.3; range, 0-3). The other group consisted of 13 patients, one with multisystem organ failure, who presented with infected necrosis (median Atlanta score, 0.4; range, 0-3). Differences between the group with sterile and the group with infected necrosis were analyzed with the Fisher-Holton exact and Mann-Whitney U tests.Among 35 patients, 17 (49%) were treated successfully with CT-guided percutaneous catheter drainage alone. The effectiveness of CT-guided percutaneous catheter drainage in patients with sterile necrosis (11/22, 50%) was not significantly different from that of drainage in patients with infected necrosis (6/13, 46%). Among 11 patients with multisystem organ failure (10 with sterile necrosis, one with infected necrosis), only four (36%) were treated successfully with CT-guided percutaneous catheter drainage alone; five patients (45%) died. Among 24 patients without multisystem organ failure, 13 (54%) were treated successfully with CT-guided percutaneous catheter drainage alone; one patient died.In our experience, primary CT-guided percutaneous catheter drainage was successful for approximately one half of the patients with acute necrotizing pancreatitis. The presence of multisystem organ failure appears to be a more important indicator of outcome than does the presence of infection.

Orthotopic liver transplantation is the standard of care in patients with Budd-Chiari syndrome (BCS), and transjugular intrahepatic portosystemic shunt (TIPS) has become an important adjunct procedure while the patient is waiting for a liver. No long-term follow up of TIPS in BCS patients has been published in children. We report successful 10-year follow-up of a child with BCS and iatrogenic TIPS dysfunction caused by oral contraceptive use.

Imaging plays a vital role in the evaluation of adrenal pathology. The most widely used modalities are computed tomography and magnetic resonance imaging. Alone or in conjunction with appropriate clinical and biochemical data, imaging can provide specific diagnoses that preclude the need for tissue sampling. This article reviews imaging features of normal and diseased adrenals, from both benign and malignant causes. Procedimentos de imagem têm um papel vital na avaliação da patologia adrenal. As modalidades mais amplamente empregadas são a tomografia computadorizada e a imagem por ressonância magnética. Isoladas ou em combinação com dados clínicos e bioquímicos apropriados, a imagem pode prover diagnósticos específicos que dispensam a necessidade de amostras de tecido por biopsia. Este artigo revisa os achados de imagem da adrenal normal e patológica, incluindo tanto causas benignas como malignas.

Primary and metastatic tumours of the spleen are uncommon. The incidence of isolated metastasis from other organs is less than 1%. We report the case of a 55-year-old woman with clear cell carcinoma of the kidney, who underwent radical nephrectomy. After a 5-year follow-up period, a hypervascular nodule was detected in the spleen on MRI. Six months later, control MRI showed that its appearance had changed to a hypervascular mass with areas of central necrosis. A splenectomy was performed and histopathological examination of the spleen confirmed the presence of clear cell carcinoma with infiltration of the capsule. This is only the seventh case described in the literature of isolated splenic metastasis from clear cell carcinoma and the first such case containing MRI.