Selective Arterial Injection Research Articles

Arterial vascularization of the mandible and soft tissues. Anatomic study.

The literature has for too long described the arterial supply of the mandible as coming from a single artery, the inferior alveolar artery, and being of the terminal type. Rather, it appears to come from an extensive and complex arterial network dependent on the lingual, facial, and maxillary arteries and their collateral branches. Our study aims to confirm and demonstrate the arterial vascular richness of the mandible and to establish arterial mapping. The arterial vascularization of the mandible was revealed in six anatomic specimens after performing selective injections of the lingual, facial, and maxillary arteries with different dyes. A specimen was injected intra-arterially with colored latex at the level of the maxillary artery for a morphometric study. Eighteen selective arterial injections were performed on six anatomic specimens. The mucocutaneous, musculoperiosteal, and intramedullary vascularizations were analyzed. Each of the arteries has a defined and delimited cutaneo-mucous vascular territory. The facial and maxillary arteries supply the musculoperiosteal vascularization of the mandible from the condyle to the symphysis. The lingual artery supplies only the inner cortex of the parasymphyseal and symphyseal regions. The facial and maxillary arteries provide intramedullary vascularization from the angle of the mandible to the parasymphysis. The vascularization of the symphysis depends on the facial artery. No staining was found in the condyle region. Neoprene latex injection was performed on an anatomic specimen, revealing a permeable anastomosis between the inferior alveolar and facial arteries. The arterial vascularization of the mandible is dependent on the maxillary, facial, and lingual arteries. This is a network vasculature. This study makes it possible to establish an arterial map of the mandible. The presence of an anastomosis between the inferior alveolar artery and the facial artery confirms the existence of dynamic and borrowed vascularization. Knowledge of this arterial system makes it possible to adapt maxillofacial surgical care and to anticipate possible intraoperative complications.

Selective ophthalmic arterial injection using a balloon catheter for retinoblastoma: a seven-year clinical evaluation.

To evaluate the effectiveness and safety of selective ophthalmic arterial injection (SOAI) for retinoblastoma utilizing a microballoon catheter system with an M chamber. Retrospective analysis. This study was sanctioned by theNational Cancer Center Hospital' Independent Ethics Committee. The surgeon was a general interventional radiologist. After confirming that the distal internal carotid artery was not delineated by balloon occlusion and the ophthalmic artery was visualized using digital subtraction angiography, melphalan was manually administered. Notably, in cases presenting bilateral retinoblastoma, both eyes received treatment in a singular, low-dose procedure. Between July 2015 and December 2021, 125 patients with retinoblastoma (68 boys and 57 girls) underwent SOAI at our facility. The average age at initial treatment was 19.3 months. The study covered 250 procedures, with patients undergoing an average of 3.7 procedures. The success rate of the procedure was 99.2%, with a mean procedure duration of 18.3min. Two distinct technical failures were recorded: one attributed to an internal carotid artery having a wide lumen and the other due to the ophthalmic artery remaining undetected on angiography post-balloon occlusion of the internal carotid artery. Adverse events were minimal but included bronchospasm post-procedure and severe orbital inflammation in 0.8% and 0.4% of cases, respectively. SOAI using the microballoon catheter with the M chamber is a feasible and safe procedure for the treatment of retinoblastoma. The success rate was 99.2%. This system can be recommended as intra-arterial chemotherapy for retinoblastoma.

The Future of Interventions for Stage IV Colorectal Cancers

AbstractFuture options for the management of stage IV colorectal cancer are primarily focused on personalized and directed therapies. Interventions include precision cancer medicine, utilizing nanocarrier platforms for directed chemotherapy, palliative pressurized intraperitoneal aerosol chemotherapy (PIPAC), adjunctive oncolytic virotherapy, and radioembolization techniques. Comprehensive genetic profiling provides specific tumor-directed therapy based on individual genetics. Biomimetic magnetic nanoparticles as chemotherapy delivery systems may reduce systemic side effects of traditional chemotherapy by targeting tumor cells and sparing healthy cells. PIPAC is a newly emerging option for patients with peritoneal metastasis from colorectal cancer and is now being used internationally, showing promising results as a palliative therapy for colorectal cancer. Oncolytic virotherapy is another emerging potential treatment option, especially when combined with standard chemotherapy and/or radiation, as well as immunotherapy. And finally, radioembolization with yttrium-90 (90Y) microspheres has shown some success in treating patients with unresectable liver metastasis from colorectal cancer via selective arterial injection.

Fibula free flap perforasomes: vascular anatomical study and clinical applications

This study assesses the anatomical features of the cutaneous fibular perforators and perforasomes of fibular free flap to determine the clinical implications therein. This anatomical study was performed with 16 fresh cadavers after selective arterial injections of inked serum. The numbers of perforators, diameter, location of the perforasome center, perforator course, the distance between perforator origin and tibiofibular division, and the perforasome area were all documented. Thirty-one lower legs were dissected. Eighty-eight cutaneous perforators were found, averaging 2.8 per leg (1-4). The mean diameter was 1.7mm and decreased from proximal to distal (p < 0.001). The centers of the perforasomes were aligned on an oblique projection from proximal to distal and anterior to posterior. Seventeen perforators (19%) were musculocutaneous, all in the proximal half of the leg, whereas 71 perforators were septocutaneous (81%), including 18 in the proximal half of the leg. Six of the uppermost perforators originated from the fibular artery less than 10mm from the tibiofibular division. The mean area perforasome was 37.2cm2 (7.9-106cm2) and decreased from proximal to distal (p < 0.01). Distal and proximal fibular flap perforasomes sported different features. Large skin paddles supplied by large and often intramuscular perforators were found in the proximal half of the leg. Distal skin paddles were smaller, more posterior, and featured septocutaneous perforators. These factors should be considered in the skin paddle choice during the fibular free flap harvest.

Accuracy of a CBCT-based virtual injection software for vessel detection during hepatic arterial embolization

PurposeTo assess the accuracy, sensitivity, positive predictive value (PPV) and interobserver agreement of a virtual injection (VI) software that simulates selective arterial injection from nonselective cone-beam CT (CBCT) arteriography. MethodsFrom March 2019 to May 2020, 20 consecutive patients in whom a nonselective injected CBCT and a selective CT angiography (CTA) were completed in the same procedure, were retrospectively included. The position of the microcatheter tip used for selective CTA injection was identified. The VI was simulated from the exact same point on the nonselective CBCT and the two volumes were merged. VI was compared to the real injection on the selective CTA. Three interventional radiologists evaluated the accuracy using a 6-point scale (Perfect; Good; Fair; Incorrect Origin; False Negative; Non existing). Sensitivity, PPV, and Fleiss’ kappa were calculated. Numerical variables were presented as means ± standard deviations. ResultsTwenty procedures and 195 vessel segments were analyzed. Most vessels were 4th order (57/195; 29%) and 5th order (96/195; 49%). VI was classified as perfect to good in 96.8% ± 1.4 of 1st–3rd order arteries and in 83.4% ± 0.4 of 4th–5th order arteries. Interobserver agreement was substantial (Fleiss’ kappa = 0.79; 95% confidence interval = 0.73–0.84, P < 0.01). False negatives were reported with a mean of 9.4% ± 0.3. Average sensitivity was 90.6% ± 0.3 and average PPV was 92.7% ± 0.02. Fourteen false positives were noted. ConclusionCBCT-based VI software accurately simulated distal injections in the liver with high sensitivity and a substantial interobserver agreement.

Complications of Selective Intraarterial Chemotherapy in Children with Intraocular Retinoblastoma

Introduction: Selective ophthalmic arterial injection (SOAI) therapy for intraocular retinoblastoma is currently recognized by the world ophthalmic-oncological communities and this method is used in leading specialized institutions. However, the using of this type of treatment can lead to complications. Side effects can be both systemic, affecting the course of the procedure itself, and local in nature, associated with intraocular changes.Purpose: Conduct an analysis of complications during SOAI in children with intraocular retinoblastoma.Material and methods: The study includes the results of treatment of 110 children (129 eyes) with unilateral and bilateral retinoblastoma who received SOAI both with insufficient efficacy of previous treatment for resistant and recurrent forms of RB (99 children / 116 eyes), and as primary local chemotherapy without previous treatment (11 patients / 13 eyes). 313 procedures were performed, of which the treatment stage was completed in 303 cases. Depending on the hemodynamic characteristics of the blood supply to the eye and the orbital region, 2 methods of delivering of the chemotherapy were used: 1) microcatheter technique (245 procedures performed; 81.0 %) 2) microballoon technique (58 procedures performed; 19.0 %).Results: The structure of the complications was as follows. 1. The group of intraoperative complications included: spasm of the ICA, cerebral arteries — 4 cases (1.3 %), acute cardio-respiratory manifestations and hemodynamic instability — 93 (29.7 %). 2. Group of general complications: cerebrovascular accident — 3 cases (0.9 %), hematological toxicity — 14 (4.5 %). 3. Group of local complications. A) External extraocular manifestations: transient eyelid edema — 49 (15.7 %), frontal arteritis — 2 (0.6 %), ptosis of the upper eyelid — 11 (3.5 %), ptosis and deviation of the eyeball — 2 ( 0.6 %), soft tissue necrosis — 1 (0.3 %). B) Intraocular manifestations: retinal detachment — 13 (4.2 %), chorioretinal atrophy — 4 (1.2 %), edema of the optic nerve head — 2 (0.6 %), atrophy of the optic nerve head — 1 (0.3 %), hemophthalmia — 3 (0.9 %).Conclusion: Modern interventional endovascular methods allow to carry out the SOAI safety and reduce the number of possible complications.

Intraoperative Identification of the Shunt Point of Spinal Arteriovenous Malformations by a Selective Arterial Injection of Saline to Subtract Signals of Indocyanine Green: Technical Note

It is crucial to identify a shunt point for spinal arteriovenous malformation (AVM) treatment. For this purpose, some intraoperative supports have been reported-intravenous injection of indocyanine green (ICG), selective arterial injection of ICG, and selective arterial injection of saline with a high frame rate digital camera. However, there are difficulties in accurately identifying the shunt point, especially if the lesion has multiple feeders. The aim of this technical note was to report a novel method, selective arterial injection of saline to subtract signals of ICG, to precisely identify perimedullary arteriovenous fistula shunt points having multiple feeding arteries. After exposing the lesion, a 4-F catheter was cannulated into the origins of the segmental artery. ICG was injected intravenously as a first step, and then heparinized saline solution was flushed from the catheter. Compared with other methods, this method could identify the exact shunt point and was effective for certain shunt point obliterations. Despite having similar invasiveness, selective arterial injection of saline to subtract signals of ICG is superior to previously described techniques, such as selective arterial injection of ICG. Therefore, it will be useful in spinal arteriovenous malformation surgical treatment.

Clinical spectrum and treatment outcome of retinoblastoma with Group D and E diseases: A single institution retrospective review.

The purpose of our study was to evaluate the ocular survival and event-free survival after multimodal therapy for group D and E of retinoblastoma (RB). Enucleation of group D and E is controversial as the risks of chemotherapy must be weighed against the potential for vision.A 10-year retrospective study from one center of 86 patients with advanced intraocular disease defined as International Classification Retinoblastoma (ICRB) group “D” or “E.” Cases with visible extraocular extension at diagnosis were excluded. Ocular survival and patient survival were assessed. Indirect ophthalmoscopy at examination under anesthesia to visualize the tumor was used to evaluate clinical response.The median onset age in 86 patients with group D or E eye was 16 months (1–167 months). There were 29 (34%) bilateral cases. Leukocoria was the most common presentation sign (61%). Chemoreduction was primarily used in the treatment of intraocular RB. Selective ophthalmic arterial injection (SOAI) was applied as a component of multimodal therapy in 34 of the 86 cases. The globe preservation rate in patients with group D or E eyes was 19%. Using chemoreduction for advanced eyes, more eyes are being preserved which enables 70% 5-year ocular survival in patients with group D eyes.In triaging appropriate patients, multidisciplinary strategy can reduce tumor size with chemoreduction and consolidate the regressed tumor with local ophthalmic therapy to ensure globe salvage.

Histopathologic findings after selective ophthalmic arterial injection of melphalan for retinoblastoma.

PURPOSE:The aim is to describe histopathologic observations in eyes enucleated after selective ophthalmic arterial injection (SOAI) of melphalan for retinoblastoma (RB).STUDY DESIGN:This is retrospective clinical study.PATIENTS AND METHODS:Histopathologic analysis of 14 eyes (13 patients) from May 2008 through January 2015 at Chang Gung Memorial Hospital.RESULTS:The eyes after SOAI were enucleated due to tumor viability (n = 7, 2 with vitreous hemorrhage), neovascular glaucoma (n = 4), lens drop to vitreous with total hyphema and elevated intraocular pressure (n = 1), retinal detachment (RD) progressed (n = 1), and persistent RD with phthisis change (n = 1). Almost all of the eyes showed vitreous seeding (n = 11 eyes) before treatment. After the treatment of SOAI, the histopathological examination revealed complete regression in four eyes with one was clinically diagnosed as viable tumor and progression, one with RD progression, and two as neovascular glaucoma. Six eyes showed invasion into the optic nerves, reaching the lamina cribrosa in five eyes, and six eyes with invasion into the choroid were observed. All of the cases with lamina cribrosa involvement showed tumor progression before enucleation, four cases with lamina cribrosa involvement expired later.CONCLUSION:Although some cases of RB can be controlled effectively with SOAI, but for refractory cases after SOAI, earlier decision of enucleation may be needed.

Simultaneous hyperthermia-chemotherapy effect by arterial injection of Fe(Salen) for femur tumor.

We previously identified a novel nanomagnetic particle, N,N′‐bis(salicylidene)ethylenediamine iron [Fe(Salen)]. Fe(Salen) not only shows antitumor effects but also magnetic properties. We found that Fe(Salen) can be used for magnet‐guided drug delivery and visualization of accumulated drug by magnetic resonance imaging (MRI) because of its magnetism. In addition, Fe(Salen) can generate heat by itself when exposed to an alternating current magnetic field (AMF), resulting in a hyperthermia effect. Herein, we partly elucidated the antitumor mechanism of Fe(Salen) and carried out an i.v. repeated dose toxicity study to decide the therapeutic amount. Furthermore, we evaluated the antitumor effect of selective intra‐arterial injection or i.v. injection of Fe(Salen) by catheter and the hyperthermia effect of Fe(Salen) when exposed to AMF in vivo. We used a rabbit model grafted with VX2 cells (rabbit squamous cell carcinoma) on the right leg. Intra‐arterial injection of Fe(Salen) showed a greater antitumor effect than did i.v. injection. The combination of Fe(Salen) intra‐arterial injection and AMF exposure showed a greater antitumor effect than did either Fe(Salen) or methotrexate (MTX) without AMF exposure, suggesting that AMF exposure greatly enhanced the antitumor effect of Fe(Salen) by arterial injection by catheter. This is the first report that the effectiveness of Fe(Salen) was evaluated in the point of administration route; that is, selective intra‐arterial injection by catheter. Taken together, these results indicate a new administration route; that is, selective arterial injection of Fe(Salen) by catheter, and the development of a new strategy of simultaneous hyperthermia‐chemotherapy in the future.

A primary hepatic gastrinoma accompanied by hyperplasia of multi-nodular Brunner\u2019s glands

BackgroundPrimary hepatic gastrinoma causing severe ulcerogenic syndrome is extremely rare. Herein, we report a case of primary hepatic gastrinoma accompanied by hyperplasia of multi-nodular Brunner’s glands in a patient who instead, preoperatively, was suspected of having multiple duodenal gastrinomas and hepatic metastasis.Case presentationA 57-year-old woman consulted a clinic complaining of melena, intermittent abdominal pain, diarrhea, and vomiting which had persisted for about 3 years. Six months before her presentation, she underwent segmental resection of the jejunum for acute peritonitis due to the spontaneous jejunal perforation. A blood test revealed that her serum immunoreactive gastrin (IRG) level was 12,037 pg/mL. Subsequently, she was transferred to our hospital. On computed tomography (CT), a hypervascular tumor of 23 mm in the segment 5 (S5) region of the liver was visualized. A selective arterial secretagogue injection test (SASI test) was performed twice. The first SASI test revealed that the hepatic tumor was a gastrinoma, and there was no gastrinoma in the duodeno-pancreatic region. Additionally, somatostatin receptor scintigraphy only visualized the tumor in the liver. However, the second SASI test, which was performed during the administration of a proton pump inhibitor and a somatostatin analog (octreotide acetate), revealed that there may have been gastrinomas existing not only in the liver but also in the upper part of the duodenum or the head of the pancreas. Duodenal endoscopy revealed multiple submucosal tumors in the first and the second portion of the duodenum, although a pathological examination of biopsied specimens obtained from the duodenal lesions was negative for malignant cells. Multiple endocrine neoplasia type 1 (MEN1) was excluded from her family history, and serum levels of both intact parathyroid hormone (iPTH) and calcium were within normal ranges. An anterior segmentectomy of the liver and pancreas-preserving total duodenectomy were performed on September 9, 2013. Postoperatively, her serum immunoreactive gastrin level decreased to less than 50 pg/mL. Pathological study of the resected specimens revealed a gastrinoma in the liver, but no gastrinoma in the duodenum. Interestingly, the duodenal submucosal tumor-like lesions were hyperplastic Brunner’s glands. Postoperatively, she has been well without recurrence of hypergastrinemia for 4 years.ConclusionWe report a case of primary hepatic gastrinoma in a patient who has been cured for 4 years postoperatively. The diagnosis was somewhat difficult due to the coexisting, multiple hyperplastic Brunner’s glands of the duodenum mimicking the submucosal neuroendocrine tumors, which might have developed due to long-term hypergastrinemia.

Dynamic Measurement of Arterial Liver Perfusion With an Interventional C-Arm System.

Objective intraprocedural measurement of hepatic blood flow could provide a quantitative treatment end point for locoregional liver procedures. This study aims to validate the accuracy and reproducibility of cone-beam computed tomography perfusion (CBCTp) measurements of arterial liver perfusion (ALP) against clinically available computed tomography perfusion (CTp) measurements in a swine embolization model. Triplicate CBCTp measurements using a selective arterial contrast injection were performed before and after complete embolization of the left lobe of the liver in 5 swine. Two CBCTp protocols were evaluated that differed in sweep duration (3.3 vs 4.5 seconds) and the number of acquired projection images (166 vs 248). The mean ALP was measured within identical volumes of interest selected in the embolized and nonembolized regions of the perfusion map generated from each scan. Postembolization CBCTp values were also compared with CTp measurements. The 2 CBCTp protocols demonstrated high concordance correlation (0.90, P < 0.001). Both CBCTp protocols showed higher reproducibility than CTp in the nontarget lobe, with an intraclass correlation of 0.90 or greater for CBCTp and 0.83 for CTp (P < 0.001 for all correlations). The ALP in the embolized lobe was nearly zero and hence excluded for reproducibility. High concordance correlation was observed between the CTp and each CBCTp protocol, with the shorter CBCTp protocol reaching a concordance correlation of 0.75 and the longer achieving 0.87 (P < 0.001 for both correlations). Dynamic blood flow measurement using an angiographic C-arm system is feasible and produces quantitative results comparable to CTp.

Should the Selective Arterial Secretagogue Injection Test for Insulinoma Localization Be Evaluated at 60 or 120 Seconds?

Objective The selective arterial secretagogue injection (SASI) test is considered indispensable for the accurate localization of insulinoma. However, the optimum timing of the post-injection evaluation is controversial, as some studies recommend 60 seconds [SASI (60 seconds)] while others support 120 seconds [SASI (120 seconds)]. The aim of this study was to determine the optimum timing for the SASI test evaluation for insulinoma localization. Methods Thirteen patients with surgically proven insulinoma were studied retrospectively. For the SASI test, immunoreactive insulin (IRI) was determined at baseline and at 30, 60, 90, and 120 seconds after calcium gluconate injection. A two-fold or greater increase in IRI over the baseline value was considered positive. The localization abilities of SASI (60 seconds) and SASI (120 seconds) were then compared. Results In 13 patients, a secretagogue was injected into 40 arteries supplying the pancreas. In the SASI (60 seconds) and SASI (120 seconds), the respective findings were as follows: positive predictive value, 72.2% and 68.2%; false positive rate, 25.0% and 35.0%; and rate of positivity in the head and body/tail, 38.5% and 46.2%. When the artery with the largest change was taken as the dominant artery, the localization detection sensitivity was 76.9% for SASI (60 seconds) and 92.3% for SASI (120 seconds). The sensitivity of morphological imaging techniques for localization ranged from 61.5-91.7%. Conclusion Compared with SASI (60 seconds) or morphological imaging, the insulinoma localization ability of SASI (120 seconds) was superior. Given these findings, we believe that the IRI level should be measured at 120 seconds in the SASI test.

Localization of Insulinoma Using 68Ga-DOTATATE PET/CT Scan.

Reliable localization of insulinoma is critical for successful treatment. This study compared the accuracy of 68Gallium DOTA-(Tyr3)-octreotate (Ga-DOTATATE) positron emission tomography (PET)/computed tomography (CT) to anatomic imaging modalities, selective arterial secretagogue injection (SASI), and intraoperative ultrasound (IO ultrasound) and palpation for localizing insulinoma in patients who were biochemically cured. We conducted a retrospective analysis of 31 patients who had an insulinoma. The results of CT, magnetic resonance imaging (MRI), ultrasound, IO ultrasound, 68Ga-DOTATATE PET/CT, SASI, and operative findings were analyzed. The insulinomas were correctly localized in 17 out of 31 (55%) patients by CT, in 17 out of 28 (61%) by MRI, in 6 out of 28 (21%) by ultrasound, and in 9 out of 10 (90%) by 68Ga-DOTATATE. In 29 of 31 patients (93.5%) who had IO ultrasound, an insulinoma was successfully localized. Thirty patients underwent SASI, and the insulinoma was regionalized in 28 out of 30 patients (93%). In 19 out of 23 patients (83%), manual palpation identified insulinoma. In patients who had all 4 noninvasive imaging studies, CT was concordant with 68Ga-DOTATATE in 6 out of 9 patients (67%), MRI in 8 out of 9 (78%), ultrasound in 0 out of 9; the lesion was only seen by 68Ga-DOTATATE in 1 out of 9 (11%). 68Ga-DOTATATE PET/CT identifies most insulinomas and may be considered as an adjunct imaging study when all imaging studies are negative and when a minimally invasive surgical approach is planned.

Prostate Perfusion Mapped by Technetium-99m Macroaggregated Albumin after Selective Arterial Injection

PurposeTo determine if perfusion of the prostate can be mapped using technetium-99m (99mTc) macroaggregated albumin (MAA) after selective prostate artery catheterization. Materials and MethodsSelective prostate artery injections of MAA were performed and analyzed in 14 patients; 9 patients received unilateral injection, and 5 patients received bilateral injections (37 MBq/1 mCi per injection). Fused single-photon emission computed tomography/computed tomography (SPECT/CT) images were subsequently acquired using a fiducial marker technique. Perfusion distribution was assessed, and relative intraprostatic versus extraprostatic activity was quantified and compared between groups. ResultsThe percentage of the prostate gland containing activity was significantly greater for the bilateral injection group compared with the unilateral injection group (76.6% vs 44.3%, P < .05). The percentage of relative intraprostatic versus extraprostatic activity was significantly lower for the bilateral injection group compared with the unilateral injection group (40.3% vs 75.9%, P < .05). Sites of visualized extraprostatic activity included the seminal vesicles (8 of 14 patients), internal iliac vessels (7 of 14 patients), bladder wall (5 of 14 patients), space of Retzius (3 of 14 patients), rectal wall (3 of 14 patients), and penis (1 of 14 patients). ConclusionsPerfusion mapping with 99mTc-MAA can be effectively performed with SPECT/CT after selective prostate artery catheterization. The relative percentage of intraprostatic versus extraprostatic activity can be quantified, and the distribution of activity within and outside the prostate gland can be determined.

Selective ophthalmic arterial injection of melphalan for intraocular retinoblastoma: a 4-year review.

To describe tumor response and complications after selective ophthalmic arterial injection (SOAI) of melphalan for treatment of intraocular retinoblastoma. A retrospective review of 17 eyes (12 patients) treated with SOAI of melphalan from January 2010 through December 2013 at Chang Gung Memorial Hospital. SOAI was successfully performed in 49 of 54 attempts. Six eyes underwent SOAI as the primary treatment and 11 eyes had previously been treated with other treatment modalities. Subsequent to SOAI, tumor regression was observed in 12 of 17 eyes, and vitreous seeding with complete or partial regression in ten of 15 eyes. Globe salvage was achieved in ten of 17 eyes, with three of four in group B and group C eyes, and seven of 13 in group D and group E eyes. Pancytopenia accompanied by neutropenic fever was observed in one case. Twelve eyes had local side effects, including lid edema (two eyes), third cranial nerve palsy (two eyes), sixth cranial nerve palsy (one eye), chorioretinal atrophy (six eyes), retinal arterial occlusion (three eyes), retinal detachment (one eye), and vitreous hemorrhage (seven eyes). Three cases with high-risk features, according to the histopathologic examination, had metastatic disease, and two of them died. SOAI of melphalan is an effective treatment for intraocular retinoblastoma, achieving high globe salvage in cases of advanced disease, but can be associated with significant ocular complications. Repetitive SOAI with delayed enucleation could increase the risk of metastasis when used in high-risk cases. Therefore, clinicians should consider the benefits and potential risks and use this new technique with caution.

Comparison of two low‐dose calcium infusion schedules for localization of insulinomas by selective pancreatic arterial injection with hepatic venous sampling for insulin

Localization of small insulinomas may be difficult. Selective pancreatic arterial injection of calcium with hepatic venous insulin measurement (SACST) has been used for this purpose, but can rarely cause hypoglycaemia. Two low-dose concentrations of calcium, 0·25 and 0·1 of the usual concentration used for the test, have been compared for sensitivity of localization and safety. Selective pancreatic arterial injection of calcium with hepatic venous insulin measurement was performed at calcium concentrations of 0·0025 (Protocol A) and 0·00625 (Protocol B) mEq calcium per kg. The standard concentration is 0·025 mEq/kg. Twenty one successive patients with biochemical evidence of insulinoma were studied. Using surgical localization as the gold standard, Protocol A had a sensitivity of 91% and Protocol B 75% for correct localization. The false-positive localization rate was 16%. No hypoglycaemia was observed. These results compare favourably with published data using the standard calcium concentration. Selective pancreatic arterial injection of calcium with hepatic venous insulin measurement was superior to localization by noninvasive imaging; in seven cases, SACST was correct when conventional imaging was negative (five) or false positive (two). Low concentrations of calcium are effective and safe when performing SACST for localization of insulinoma.

Hemobilia due to biliary intraepithelial neoplasia associated with Zollinger-Ellison syndrome.

A 58-year-old man was transferred to us from his local hospital because of failure to control his gastrointestinal bleeding by endoscopic hemostasis. Abdominal imaging suggested a hypervascular tumor of the pancreatic head (36mm diameter), and laboratory testing showed an elevated serum gastrin level (17,800pg/mL). Gastroduodenal endoscopy revealed multiple duodenal ulcers and active bleeding from the ampulla of Vater. The selective arterial secretagogue injection test suggested a gastrinoma in the pancreatic head, but no gastrinoma in the pancreatic tail. The patient was diagnosed with solitary pancreatic head gastrinoma complicated by hemosuccus pancreaticus, and pancreaticoduodenectomy was performed. Intraoperatively, the diagnosis was changed to primary peripancreatic lymph node gastrinoma without pancreatic involvement. The gastrointestinal bleeding stopped postoperatively and serum gastrin levels returned to normal. Histological examination of the surgical specimens revealed a small submucosal gastrinoma in the duodenum (7mm diameter). The final diagnosis was microgastrinoma of the duodenum with peripancreatic lymph node metastasis. The cause of bleeding from the ampulla of Vater was initially obscure, but eventually a hemorrhagic erosion with moderate atypia was found in the common bile duct, indicating biliary intraepithelial neoplasia (BilIN). This is the first report of hemobilia due to BilIN with gastrinoma.

Abdominal Pain and Liver Lesions in Zollinger‐Ellison Syndrome

van Os, Erim Schrama, Martijn Kamphuis, Karin de Herder, Wouter W Damen, Gerard M Case Reports United States J Pediatr Gastroenterol Nutr. 2012 Mar;54(3):435-7.

The Current Strategy for Managing Pancreatic Neuroendocrine Tumors in Multiple Endocrine Neoplasia Type 1

Multiple endocrine neoplasia type 1 (MEN1) is an inherited autosomal dominant disease presenting with pancreatic neuroendocrine tumors (pNETs), parathyroid tumors, or pituitary tumors. Using the PubMed database, we reviewed the literature on information regarding the proper diagnosis and treatment of MEN1-associated pNET. Many cases of MEN1-associated pNET are functioning pNETs. Gastrinomas and insulinomas tend to occur frequently in the duodenum and pancreas, respectively. In addition to diagnostic imaging, the selective arterial secretagogue injection test (SASI test) is useful for localizing functioning pNET. The standard treatment is surgical resection. However, in the case of a functioning pNET, the tumor should first be accurately located using the SASI test before an appropriate surgical method is selected. In cases of a MEN1-associated non-functioning pNET that exceeds 2 cm in diameter, the incidence of distant metastasis is significantly increased, and surgery is recommended. In cases of unresectable pNET, a somatostatin analog has been shown to demonstrate antitumor effects and is considered to be a promising treatment. In addition, molecular-targeted drugs have recently been found to be effective in phase III clinical trials.