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Pancreaticoduodenal artery (PDA) aneurysm and celiac artery (CA) stenosis are rare diseases in themselves. Interestingly, however, there are more cases documented in the literature in which these two disease entities occurred together than could be coincidental, and CA stenosis has been suggested as the provocative condition in developing PDA aneurysm. This study is aimed at examining the causal relationship between CA stenosis and PDA aneurysm by simulating the splanchnic circulation with an electric circuit. A patient with multiple PDA aneurysms and collaterals with CA stenosis was treated in our institution using hybrid techniques. The patient's pre- and postoperative status was simulated using an electric circuit, and the two possible scenarios were tested for compatibility: the stenosis-first scenario vs. the aneurysm-first scenario. The simulation was performed in two ways: using Simulink® software (MATLAB® Release 2018b) and actual circuit construction on a breadboard. The stenosis-first scenario showed that as the CA stenosis progresses, the blood flow through PDA increases, favoring the development of an aneurysm and/or collaterals if the artery was already compromised by a weakening condition. On the other hand, the aneurysm-first scenario also showed that if the aneurysm or collaterals developed first, the aneurysm will steal the blood flow through the CA, causing it to collapse if the artery was already compromised by increased wall tension. Contrary to the common belief, this study showed that in patients suffering from concurrent CA stenosis and PDA aneurysm, either condition could develop first and predispose the development of the other. The simulation of splanchnic blood flow with an electric circuit provides a useful tool for analyzing rare vascular diseases that are difficult to provoke in clinical and animal studies., Competing Interests: The authors declare that there are no conflicts of interest., (Copyright © 2020 Hye Jeong Yoon et al.)

Background: To explore the patterns of failures and areas at highest risk of recurrence for postoperative intrahepatic cholangiocarcinoma (IHCC), with the aim to guide IHCC adjuvant radiotherapy., Methods: Patients with IHCC who had undergone radical surgery at our institution from July 2010 to August 2017 were retrospectively analyzed. The survival and prognostic factors were analyzed by univariate and multivariate analysis. All sites of recurrence were found out and classified as the surgical margin, regional lymph nodes, liver remnant and distant metastasis. According to the recurring area at highest risk, the target volume of adjuvant radiotherapy was proposed., Results: The median follow-up time was 23.5 months (2-85 months). The median recurrence free survival (RFS) and overall survival (OS) were 12.1 months and 24.8 months, respectively. Seventy-three (73/127, 57.5%) IHCC patients developed tumor recurrence. Initial recurrences occurred in the potential postoperative radiotherapy (PORT) volume, remnant liver and distant sits were 46 (46/73, 63.0%), 36 (36/73, 49.3%) and 22 (22/73, 30.1%) cases, respectively. Of the 46 patients whose initial recurrence inside the potential PORT volume, 29 (29/73, 39.7%) developed recurrence only inside the potential PORT volume, including 13 tumor bed recurrences, 7 lymph node metastases, and 9 with both tumor bed recurrences and lymph node metastases. The most common lymph node metastases sites were nodes around the abdominal aorta, followed by lymph nodes along the celiac artery, the common hepatic artery, and in the hepatoduodenal ligament., Conclusions: High proportion of the recurrences occurred only inside the potential PORT volume, implying adjuvant radiotherapy might improve the local-regional control. Surgical margins and lymph node stations No.16a2, 9, 8, 12, 13, and 14 are suggested to be included in the radiation volume.

Background: A chylothorax is a rare complication of mostly advanced malignant lymphomas. A case of a refractory chylothorax unresponsive to chemotherapy and successfully treated with radiotherapy is reported., Case Report: A 45-year-old woman with recurrent stage IV low-grade follicular non-Hodgkin's lymphoma and a progressive chylothorax is described. The CT scans showed bulky lymphadenopathy at the thoracic trunk but no detectable enlargement of mediastinal lymph nodes. After ineffective pretreatment including chemotherapy and chest drainage, fractionated radiotherapy to the celiac trunk (20.4 Gy) and the thoracic duct (15 Gy) was performed., Result: Already after 7.5 Gy a rapid decline of chylothorax was noted and the chest drain could be removed. A complete remission of the chylothorax could be achieved after 20.4 Gy. During a follow-up of 16 months no recurrence of chylothorax occurred. CT scans showed nearly complete remission of the lymphadenopathy of the celiac trunk 12 months after radiotherapy., Conclusion: Radiotherapy with limited total doses is an effective treatment option for lymphoma-associated chylothorax and should always be taken into consideration, especially in cases unresponsive to chemotherapy.

Aim: To demonstrate changes in gastric mucosal blood flow caused by intraoperative radiotherapy of the celiac artery combined with external radiotherapy of the upper abdomen in a rabbit model. The study was designed to identify a possible correlation between a radiation-induced reduction in mucosal blood flow and the induction of gastric ulcer., Material and Method: Intraoperative radiation doses of 0 or 30 Gy were given to the celiac artery in rabbits. After a delay of 14 days external radiotherapy of the upper abdomen with 3 x 4 Gy/week to a maximum total dose of 40 Gy was initiated. Gastric mucosal blood flow was assessed by intraventricular injection of radioactively-labelled microspheres (15 microns) followed by measurement of radioactivity in the mucosa. The injections were performed at various time intervals between 2 and 63 days after intraoperative radiation., Results: Intraoperative radiotherapy, including sham-intraoperative radiation, resulted in a transitory reduction of mucosal blood flow by about 50% of the control value on day 7 (Figure 3). After a temporary recovery by day 14, a marked and permanent reduction in blood flow was assessed after week 6. This time corresponds to the time of development of gastric ulcer., Conclusions: A relationship between the time of ulcer development and of reduced gastric mucosal blood flow was observed after combined intraoperative and external radiotherapy. The mechanical component of intraoperative treatment has to be emphasized. Reduced blood flow was also seen after intraoperative radiotherapy alone, without an induction of ulcer by this treatment. Hence additional mucosal damage by external radiation must be present for the induction of gastric ulcer.

The present immunohistochemical study of radiation-induced damage in major blood vessels is based on a multidisciplinary study (Schultz-Hector et al., Radiother. Oncol., 38: 205-214, 1996) investigating the combined effect of IORT of the coeliac axis and upper abdominal ERT. The paper describes the sequential changes occurring in the coeliac artery after IORT with 30 Gy, i.e. during and after combined IORT and fractionated ERT (total dose 40 Gy). Within 24 h after IORT, the arterial wall was found to be invaded by TNF-alpha positive macrophages, which later on disappeared within 7-14 days. At 2 days post-IORT, the medical smooth muscle cells were strongly positive for TNF-alpha and remained positive throughout the observation period of 63 days. At 80 days, a comparison of different IORT dose groups showed that TNF-alpha expression after 20 and 30 Gy IORT plus 40 Gy ERT had subsided, while it was still strongly evident after 40 Gy IORT. Negative reactions in sham irradiated animals or animals treated with ERT alone indicate that TNF-alpha expression was caused by IORT. After > 30 days post-IORT, there was increased collagen type I deposition in the adventitia. In two animals receiving the full ERT course, intimal proliferations involving mainly smooth muscle cells were observed. Our findings indicate that some features typical of radiation induced arteriosclerosis such as periarterial fibrosis and intimal proliferations can occur as early as < 60 days postirradiation. Macrophage invasion as well as TNF-alpha expression in medial smooth muscle cells are known to be important steps in the development of spontaneous atherosclerotic lesions. Therefore, early TNF-alpha induction in the arterial wall by a high local dose of X-irradiation may be regarded as one initiating factor of chronic radiation-induced arteriosclerosis.

An experimental model in the rabbit is presented which is suitable for analysis of clinically relevant, early side-effects of combined upper abdominal IORT and ERT. Fractionated ERT alone given through an upper abdominal a.-p. field including the entire stomach caused gastric ulcerations within < or = 58 days. Latent times decreased with increasing dose and the ED50 for occurrence of ulcers was 39 +/- 3.3 Gy. Single doses of IORT of 20-40 Gy alone administered through a 2-cm diameter field localized on the coeliac axis and carefully excluding any intestinal mucosa caused neither gastric ulcerations nor other clinical symptoms. When ERT with 40 Gy was preceded by IORT with 20-40 Gy or by sham IORT, 13 out of 15 animals developed ulcers after latent times which in a life-table analysis were shown to be significantly shorter than after ERT alone. However, a statistically significant IORT dose-dependence of latent time or incidence of ulcers could not be demonstrated in the present experiment. The most significant histological changes were observed in the areas of gastric ulcers. Already during ERT, the mucosal epithelium was depleted and regenerative activity was evident in spite of ongoing fractionated irradiation. However, profound irregularities in glandular structure and distribution, as well as number of proliferating epithelial cells were still present in healed ulcers at 80 days. In summary, IORT to the coeliac artery did precipitate the development of gastric ulcers induced by subsequent ERT. On the one hand, the data indicate that the surgical procedure of IORT did contribute to this effect. On the other hand, IORT to the coeliac artery could cause transient, functional alterations in blood supply to the depending organs, i.e. the stomach, and could thus precipitate the development of radiation-induced ulcers.

Pancreatic, hepatic and intestinal troubles occurred in a 8 year-old acrogeria girl who was treated for Wilm's tumor by cobalt therapy at 2 1/2 years. Complete obstruction of the coeliac trunk and proximal superior mesenteric artery was shown, associated with hypoplasia of the abdominal aorta and its collaterals in the irradiated areas. Acrogeria might enhance the toxic effects of radiotherapy on vessels.