Anatomical Structures to Be Concerned With During Peripherally Inserted Central Catheter Procedures.

BACKGROUND: The central line has been frequently used for drug and nutrition supply and regular blood sampling of patients with chronic diseases. However, this procedure is performed in a highly sensitive area and has several potential complications. Therefore, peripherally inserted central catheters (PICC), which have various advantages, are being extensively used. Although the number of PICC procedures is increasing, the anatomy for safe procedures has not yet been properly established. Therefore, we studied basic anatomical information for safe procedures. METHODS: We used 20 fixed cadavers (40 arms) donated to the Korea University College of Medicine. The mean age was 76.75 years (range, 48-94 years). After dissection of each arm, the distribution pattern of the basilic vein and close structures was recorded, and some important parameters based on bony landmarks were measured. In addition, the number of vein branches (axillary region) and basilic vein diameter were also checked. RESULTS: The mean length from the insertion site to the right atrium was 38.39 ± 2.63 cm (left) and 34.66 ± 3.60 cm (right), and the basilic vein diameter was 4.93 ± 1.18 mm (left) and 4.08 ± 1.49 mm (right). The data showed significant differences between the left and right arms (P < 0.05). The mean distance from the basilic vein to brachial artery was 8.29 ± 2.78 mm in men and 7.81 ± 2.78 mm in women, while the distance to the ulnar nerve was 5.41 ± 1.67 mm in men and 5.52 ± 2.06 mm in women. CONCLUSION: According to these results, the right arm has a shorter distance from the insertion site to the right atrium, and the left arm has a wider vein diameter, which is advantageous for the procedure. In addition, the ulnar nerve and brachial artery were located close to or behind the insertion site. Therefore, special attention is required during the procedure to avoid damaging these important structures.

Endoscopic variceal obturation and retrograde transvenous obliteration for acute gastric cardiofundal variceal bleeding in liver cirrhosis.

BACKGROUND/AIMS: We retrospectively compared the effect of endoscopic variceal obturation (EVO) and retrograde transvenous obliteration (RTO) in acute cardiofundal variceal bleeding. METHODS: Patients with acute cardiofundal variceal bleeding treated with EVO or RTO at two hospitals were included. RESULTS: Ninety patients treated with EVO and 86 treated with RTO were analyzed. The mean model for end-stage liver disease score was significantly higher in EVO group than in RTO group (13.5 vs. 11.7, P = 0.016). The bleeding control rates were high (97.8% vs. 96.5%), and the treatment-related complication rates were low in both EVO and RTO groups (2.2% vs. 3.5%). During the median follow-up of 18.0 months, gastric variceal (GV) and esophageal variceal rebleeding occurred in 34 (19.3%) and 7 (4.0%) patients, respectively. The all-variceal rebleeding rates were comparable between EVO and RTO groups (32.4% vs. 20.8% at 2-year, P = 0.150), while the GV rebleeding rate was significantly higher in EVO group than in RTO group (32.4% vs. 12.8% at 2-year, P = 0.003). On propensity score-matched analysis (71 patients in EVO vs. 71 patients in RTO group), both all-variceal and GV rebleeding rates were significantly higher in EVO group than in RTO group (all P < 0.05). In Cox regression analysis, EVO (vs. RTO) was the only significant predictor of higher GV rebleeding risk (hazard ratio 3.132, P = 0.005). The mortality rates were similar between two groups (P = 0.597). CONCLUSIONS: Both EVO and RTO effectively controlled acute cardiofundal variceal bleeding. RTO was superior to EVO in preventing all-variceal and GV rebleeding after treatment, with similar survival outcomes.

Expert consensus on the management of adverse events in patients receiving lenvatinib for hepatocellular carcinoma.

Lenvatinib is an oral multikinase inhibitor approved for use as first-line treatment for patients with advanced hepatocellular carcinoma (HCC). However, like other agents in this drug class, lenvatinib is associated with clinically important adverse events (AEs) that could adversely affect patient outcomes. Hypertension, diarrhea, decreased appetite/weight, hand-foot skin reaction, and proteinuria are among the most common AEs associated with lenvatinib therapy. This article provides strategies for the effective management of lenvatinib-associated AEs based on the expert opinion of authors and currently available literature. Due to the high risk of AEs in patients receiving lenvatinib, prophylactic measures and regular monitoring for AEs are recommended. Lenvatinib dose interruption, adjustment, or discontinuation of treatment may be required for patients who develop AEs. For grade 1 or 2 AEs, dose interruption is generally not required. For persistent or intolerable grade 2 or 3 AEs, lenvatinib treatment should be interrupted until symptoms improve/resolve to grade 0-1 or baseline levels. Thereafter, treatment should be resumed at the same or a lower dose. Disease progression may occur in patients who do not initially respond to treatment or receive a suboptimal lenvatinib dose following dose reduction, resulting in lack of efficacy. Therefore, to derive maximum treatment benefit and ensure long-term disease control, lenvatinib should be maintained at the highest possible dose when managing AEs. To conclude, lenvatinib-associated AEs can be managed with prophylactic measures, regular monitoring and symptomatic management, which can ensure continued treatment and maximum survival benefit in patients with advanced HCC receiving first-line lenvatinib therapy.

Fluoroscopy-guided trans-urethral exchange of double-J ureteral stents.

BACKGROUND: For patients with malignant ureteral obstruction or stricture who require long-term internal drainage, plastic double-J stents (DJ stents) represent the mainstay of therapeutic strategies. DJ stents should be replaced at least once every 6 months to avoid infection or obstruction. Although DJ stents are generally replaced under cystoscopy, successful fluoroscopy-guided retrograde replacement of DJ stents in the interventional suite has been described in the literature. METHODS: Between April 2004 and May 2020, we exchanged 143 DJ stents in 19 male and 22 female patients under fluoroscopic guidance using Nelaton catheters, snare catheters, and 8F DJ stents. All procedures were performed with patients under sedation and local anesthesia. There were 39 patients with malignant ureteral obstruction and two patients with benign ureteral strictures. This study was approved by the Institutional Review Board. Technical success, clinical success, complications, procedure time, and mean interval between two procedures were retrospectively reviewed, and the factors affecting the success rate of the procedure were analyzed. RESULTS: Obstruction was detected at the abdominal ureter in 4 patients, pelvic ureter in 29 patients, and intravesical ureter in 8 patients. Twenty-six patients underwent two or more sessions of the procedures, whereas 15 patients underwent single-session procedures. Total 34 outpatient-based procedures and 109 inpatient-based procedures were performed. Technical success and clinical success were achieved in 94.4% (135/143) and 93.3% (126/135) procedures, respectively. Mean procedure time was 21.5 min (range 9-192 min). Mean procedure interval was 101.8 days (range 5-306 days). Technical success was negatively affected by male sex and obstruction at the pelvic ureter and was positively affected by previous successful exchange. Left-sided ureteral stent placement and old age negatively influenced clinical success. Septic shock occurred in one patient and was treated with antibiotics. CONCLUSION: Fluoroscopy-guided trans-urethral exchange of DJ stents is an effective and less painful procedure.

Differences in clinical outcomes according to the time interval between the bridge to surgery stenting and surgery for left-sided malignant colorectal obstruction.

BACKGROUND: Self-expandable metal stent (SEMS) placement is commonly used as a bridge to surgery (BTS) for left-sided malignant colorectal obstruction (MCO). However, the optimal time interval between BTS stenting and surgery for left-sided MCO is unclear, and the results of previous studies are conflicting. This study aimed to determine the differences in clinical outcomes according to the time interval between BTS stenting and surgery in left-sided MCO. METHODS: Data from 594 patients who underwent SEMS placement for MCO between January 2009 and December 2018 were reviewed. Among them, 148 patients who underwent SEMS placement as BTS treatment and curative surgery were enrolled. The enrolled patients were divided into three groups according to the interval between BTS stenting and surgery: group 1 (interval ≤2 weeks), group 2 (interval 2-3 weeks), and group 3 (interval >3 weeks). RESULTS: Group 2 and 3 patients underwent significantly higher rates of laparoscopic surgery than those in group 1 (83.7, 81.0 vs. 53.2 %, respectively; P=0.003, P=0.003, respectively). Also, rates of stoma formation directly after resection were significantly higher in group 1 compared to groups 2 and 3 (21.3 vs 2.3, 6.9%, respectively; P=0.008, P=0.043, respectively). Bridging interval had no effect on SEMS-related complications, resection-related complications, 90-day mortality, permanent stoma formation, 3-year disease-free survival, and 3-year overall survival. CONCLUSIONS: A bridging interval of > 2 weeks between BTS stenting and surgery for left-sided MCO is preferable for lower stoma formation rates and higher rates of laparoscopic approach operation, with no difference in short-term and long-term outcomes including complication, mortality, and survival.

Real-world systemic sequential therapy with sorafenib and regorafenib for advanced hepatocellular carcinoma: a multicenter retrospective study in Korea.

Background/Aims Regorafenib has been approved as a second-line systemic therapy for hepatocellular carcinoma (HCC) patients after the phase III RESORCE trial. This study analyzed real-world data to assess the clinical effectiveness and safety of regorafenib compared to the RESORCE trial. Methods This multicenter cohort study included HCC patients treated with regorafenib after sorafenib (n = 133). We evaluated the time to progression (TTP), progression-free survival (PFS), overall survival (OS), and safety in patients receiving regorafenib along with the predictors of prognosis. Results The median age was 60 years and 81.2% patients were men. Hepatitis B virus infection (68.4%) was the commonest etiology. Most patients were classified as Child-Pugh A (98.5%) and had extrahepatic metastasis (84%) and vascular invasion (45.1%). This study demonstrated similar characteristics apart from more frequent hepatitis B etiology and more vascular or extrahepatic involvement compared with the RESORCE trial. An objective response rate of 12.5% was obtained for response assessment (n = 112); the disease control rate was 34.8%. Thirty-eight patients died during follow-up. With regorafenib, the median OS, PFS, and TTP were 10.0, 2.7, and 2.6 months, respectively. In the exploratory analysis after sorafenib administration, the median OS was 25.8 months. The rate of response and survival were comparable to those in the RESORCE trial. Child-Pugh score > 5, alpha-fetoprotein > 400 ng/ml, and TTP for sorafenib ≥ median were independently associated with OS. Conclusions This real-word regorafenib study showed comparable effectiveness and safety to the RESORCE trial. Regorafenib improves the prognosis of patients with prolonged TTP during previous sorafenib therapy.

Direct-Acting Antivirals Improve Treatment Outcomes in Patients with Hepatitis C Virus-Related Hepatocellular Carcinoma Treated with Transarterial Chemoembolization: A Nationwide, Multi-center, Retrospective Cohort Study.

BACKGROUND AND AIMS: The influence of direct-acting antivirals (DAAs) on chronic hepatitis C (CHC)-related hepatocellular carcinoma (HCC) remains controversial. We investigated the effect of eradicating CHC using DAAs on treatment outcomes in patients with CHC-related HCC treated with transarterial chemoembolization (TACE). METHODS: This nationwide, multi-center, retrospective study recruited patients with CHC-related HCC treated with TACE as the first-line anti-cancer treatment, and who achieved a sustained virological response (SVR) using DAAs (DAA group) between 2006 and 2017. Patients achieving an SVR following interferon-based treatment (IFN group) and those without treatment (control group) were also recruited for comparison. RESULTS: A total of 425 patients were eligible for the study. Of these, 356 (83.8%), 26 (6.1%), and 43 (10.1%) were allocated to the control, IFN, and DAA groups, respectively. A multivariate analysis showed that liver cirrhosis, segmental portal vein thrombosis, and larger maximal tumor size independently predicted an increased risk of progression (all p < 0.05), whereas, the DAA group (vs. IFN and control groups) independently predicted a reduced risk of progression (hazard ratio (HR) = 0.630, 95% confidence interval 0.411-0.966, p = 0.034). The cumulative incidence rate of HCC progression in the DAA group was significantly lower than that in the IFN and control groups (p = 0.033, log-rank test). In addition, the DAA group (vs. IFN and control groups) was independently associated with a reduced risk of mortality (p = 0.042). CONCLUSIONS: DAA treatment provided significantly prolonged progression-free survival in patients with CHC-related HCC treated with TACE compared to that in patients administered IFN or no treatment.

Lifetime cancer risks from occupational radiation exposure among workers at interventional radiology departments.

PURPOSE: Interventional medical radiation workers represent an under-studied population worldwide, although they receive relatively high occupational radiation doses. This study aimed to estimate the lifetime cancer risk from occupational radiation exposure among workers at interventional radiology departments. METHODS: A field survey of interventional medical workers in nationwide branches of the Korean Society of Interventional Radiology was conducted in 2017. Organ-specific radiation doses were estimated using national dose registry data and conversion coefficients provided by the International Commission on Radiological Protection. Lifetime attributable risk (LAR) and lifetime fractional risk (LFR) were calculated based on realistic exposure scenarios using a radiation risk assessment tool. RESULTS: LARs from occupational radiation exposure until the age of retirement for all cancers combined were 338 (90.3-796.1), 121 (33.5-288.7), and 156 (41.1-390.6) per 100,000 individuals for male radiologists, male radiologic technologists, and female nurses, respectively. LFR for all cancers combined ranged from 0.22% (0.06-0.53) to 0.63% (0.17-1.47). Regarding the organ site, the highest LAR and LFR among all groups were observed for thyroid cancer. CONCLUSION: This study provides timely evidence of potential cancer burden from the current levels of occupational radiation exposure among workers at interventional radiology departments. The risks varied by occupational groups, and workers, particularly interventional radiologists, need to be carefully monitored for radiation.

Prospective Multicenter Study of the Safety of Gadoteridol in 6163 Patients.

BACKGROUND: The safety of gadolinium-based contrast agents is of fundamental importance. PURPOSE: To determine the frequency and severity of immediate-type adverse reactions to approved doses of gadoteridol in patients referred for routine gadoteridol-enhanced MRI in actual clinical practice settings. STUDY TYPE: Prospective, observational. POPULATION: In all, 6163 subjects were enrolled (mean age: 56.7 ± 15.4 years; range: 6-93 years). FIELD STRENGTH/SEQUENCE: 1.5T and 3.0T. ASSESSMENT: Assessment was of immediate adverse reactions by the investigating radiologist using the MedDRA System Organ Class and preferred term. STATISTICAL TESTS: Summary statistics for continuous variables, descriptive statistics for demographic characteristics. RESULTS: Overall, 19 adverse events occurred in 13 (0.21%) patients, of which 15 in 10 (0.16%) patients were considered related to gadoteridol administration. These events were evenly distributed between male and female subjects and all occurred in adults. Twelve of the 15 related events in eight (0.13%) patients were considered mild in intensity (rapidly self-resolving), while the remaining three events in two patients (0.03%) were considered moderate in intensity. None were of severe intensity and no serious adverse events occurred. DATA CONCLUSION: The rate of immediate-type adverse events following exposure to approved doses of gadoteridol is extremely low, and mostly limited to transient and self-resolving symptoms. LEVEL OF EVIDENCE: 2 Technical Efficacy Stage: 5 J. Magn. Reson. Imaging 2020;51:861-868.

Multidetector CT findings differ between surgical grades of pancreatic fistula after pancreaticoduodenectomy.

OBJECTIVES: To define and correlate multidetector CT (MDCT) findings of pancreatic fistula after pancreaticoduodenectomy with surgical grading based on the 2016 Revised International Study Group of Pancreatic Fistula (ISGPF) classification. METHODS: Between May 2011 and December 2016, 235 patients with periampullary tumor underwent pancreaticoduodenectomy and postoperative MDCT. Patients were classified into three groups (clinically no pancreatic fistula (cNo-PF), grade B, and grade C) according to the ISGPF classification. MDCT images were retrospectively evaluated by two radiologists in consensus for the presence of pancreaticojejunostomy (PJ) dehiscence, PJ dehiscence diameter, PJ defect, acute necrotic collection (ANC), peripancreatic fluid collection, and imaging findings of complications. Categorical MDCT findings were compared among the three groups using Pearson's chi-square test, and PJ dehiscence diameter was compared using the Kruskal-Wallis test. RESULTS: There was no significant difference in patient demographics among the groups (cNo-PF = 133, grade B = 68, and grade C = 34), but the MDCT findings were significantly different regarding the presence of PJ dehiscence (p < 0.001), PJ defect (p < 0.001), ANC (p = 0.002), and imaging findings of total complications (p < 0.001). The diameters of PJ dehiscence were significantly different among the groups (cNo-PF [0.42 ± 1.54 mm], grade B [1.47 ± 2.33 mm], and grade C [5.38 ± 6.45 mm]) (p < 0.001). CONCLUSION: With respect to the presence of PF, postoperative MDCT findings may differ between surgical grading based on the ISGPF classification. KEY POINTS: • Regarding the presence of pancreatic fistula, the postoperative multidetector CT findings correlate well with surgical grading based on the International Study Group of Pancreatic Fistula classification. • Multidetector CT may provide reliable information to suggest pancreatic fistula after pancreaticoduodenectomy.

Conventional Chemoembolization Plus Radiofrequency Ablation versus Surgical Resection for Single, Medium-Sized Hepatocellular Carcinoma: Propensity-Score Matching Analysis.

PURPOSE: To retrospectively compare long-term outcomes of conventional chemoembolization plus radiofrequency (RF) ablation vs those of surgical resection in patients with a single 3-5-cm hepatocellular carcinoma (HCC). MATERIALS AND METHODS: From January 2008 to December 2017, 139 of 623 patients who underwent surgical resection and 60 of 186 patients who underwent chemoembolization/RF ablation in a single center were compared with respect to local tumor progression (LTP), intrahepatic distant recurrence (IDR), disease-free survival (DFS), overall survival (OS), major complications, and hospital stay before and after propensity-score matching. RESULTS: Mean follow-up periods were similar in the chemoembolization/RF ablation and surgical resection groups (41.9 mo vs 48.4 mo). Three (5%) and 17 (28.3%) patients in the chemoembolization/RF ablation group and 12 (8.6%) and 57 (41.0%) patients in the surgical resection group showed LTP and IDR (P = .366 and P =.114, respectively). At 1, 3, and 5 years, respective DFS rates were 88.1%, 65.3%, and 49.0% for chemoembolization/RF ablation and 84.2%, 58.2%, and 46.5% for surgical resection (P = .294). Moreover, respective OS rates were 95.0%, 73.5%, and 54.0% for chemoembolization/RF ablation and 97.1%, 87.4%, and 75.0% for surgical resection (P = .055). After matching (n = 52), therapeutic outcomes remained similar (P = .370, P = .110, P = .230, and P = .760, respectively). Surgical resection was associated with higher complication rates (P = .015) and longer hospital stays (8.4 d ± 3.7 vs 16.9 d ± 7.0; P < .001). CONCLUSIONS: Conventional chemoembolization combined with RF ablation may be feasible for single 3-5-cm HCCs, with comparable therapeutic outcomes vs surgical resection and shorter hospital stays.

Combined Therapy with Transarterial Chemoembolization and Radiofrequency Ablation for Hepatocellular Carcinoma: Does the Degree of Ethiodized Oil Accumulation within the Tumor Affect the Therapeutic Efficacy?

PURPOSE: To evaluate the effects of the degree of ethiodized oil accumulation achieved by transarterial chemoembolization followed by radiofrequency (RF) ablation on the treatment efficacy for a single intermediate-sized hepatocellular carcinoma (HCC). MATERIALS AND METHODS: A total of 153 consecutive patients who underwent chemoembolization and RF ablation for a single intermediate-sized HCC (2-5 cm) were included. On the basis of the degree of ethiodized oil accumulation in HCC on cone-beam CT images, patients who underwent chemoembolization and RF ablation were classified into 2 groups: compact accumulation (≥ 75%) and noncompact accumulation (< 75%). The rates of cumulative local tumor progression (LTP), disease-free survival (DFS), and overall survival (OS) were compared between groups. RESULTS: Of the 153 patients, 89 were classified into the compact ethiodized oil accumulation group and 64 in the noncompact ethiodized oil accumulation group. There were no significant differences in patient demographic or HCC characteristics between groups except for the incidence of liver cirrhosis (P = .038) and the tumor margin morphology (P = .008). The cumulative LTP rate was significantly lower in the compact accumulation group than in the noncompact accumulation group (P = .013). There were no significant differences in the incidences of complications, DFS rates (P = .055), or OS rates (P = .184). CONCLUSIONS: The degree of ethiodized oil accumulation does not play a role in decreasing the OS or DFS rate after chemoembolization and RF ablation for intermediate-sized HCC; however, it may contribute to reducing the rate of LTP.

Height Loss Was Associated With Osteoporosis in Korean Elderly Men, Not in Women: The Korea National Health and Nutrition Examination Survey 2008-2010.

The degree of height loss varies among individuals, and excessive height loss can be a vertebral fracture or bone loss manifestation. The objective of this study was to examine the relationships between height loss and bone mineral density (BMD) and to assess the prevalence of osteoporosis according to the height loss quartiles. Data from the Korea National Health and Nutrition Examination Survey were analyzed. A total of 2799 participants more than 60 years old were included and subdivided into quartiles according to height loss (Q1-Q4). Height loss was calculated with the difference between the self-reported maximum adult height and the actual measured height. BMD was measured by dual-energy X-ray absorptiometry at the total femur (TF), femoral neck, and lumbar spine. Multivariable linear and logistic regression analyses were conducted to study the height loss-BMD and the height loss-osteoporosis prevalence relationships, respectively. After adjustments for all covariates, height loss was negatively associated with BMD at all the 3 sites (TF and lumbar spine, p < 0.001; femoral neck, p = 0.002) in men, but only at TF (p = 0.008) in women. Men with Q4 height loss had an increased prevalence of osteoporosis compared with those with Q1 (odds ratio = 2.092 and 95% confidence interval = 1.076-4.068). In women, the prevalence of osteoporosis was not associated with height loss. In conclusion, Q4 height loss in elderly men was associated with the increased prevalence of osteoporosis in Korea.

Clinical Outcomes of the Seal® Thoracic Stent Graft for Traumatic Aortic Injury in a Korean Multicenter Retrospective Study.

BACKGROUND: Thoracic endovascular aneurysm repair (TEVAR) has been used as a primary treatment for blunt traumatic aortic injury (TAI). However, the outcomes of midterm surveillance of Seal® stent-graft durability for TAI have not been extensively studied. Thus, we aimed to report the midterm outcomes of TEVAR using the Seal® stent graft for blunt TAI. METHODS: Patients with blunt TAI treated with TEVAR using the Seal® thoracic stent graft between 2007 and 2013 in Korea were included. Midterm outcomes included technical/clinical success, in-hospital death, aorta/procedure/device-related adverse events, secondary procedures, and 30-day and all-cause mortality. RESULTS: A total of 99 patients (54% men; mean age, 48 years) were included. Grade III or higher injuries were present in 95% of patients, including 15 free ruptures of the thoracic aorta, and 64% of injuries were located in zone III. The median procedure and hospitalization duration were 90 min and 11 days, respectively. The technical success rate was 98%. The number of in-hospital mortalities (n = 8) and stroke (n = 2) were observed at 30 days. Late stroke and paraplegia (>30 days) were not observed during the mean 49 ± 26 months of follow-up (median, 48 months; range, 0-117 months). There were no aorta-related mortalities or conversions to open repair. Secondary procedures were performed in 8 patients, all of which were carotid-subclavian bypasses for delayed left subclavian occlusion. The all-cause mortality rate was 5% at 30 days and 8% at 1 year. The survival rate was 95% at 30 days, 92% at 1 year, 92% at 3 years, and 89% at 5 years. One type Ia endoleak occurred at 18 months after the procedure. CONCLUSIONS: TEVAR with the Seal® stent graft for TAI showed favorable midterm outcomes. The incidence of major adverse events after the procedure was low.

Chronic Hepatitis B Infection Is Significantly Associated with Chronic Kidney Disease: a Population-based, Matched Case-control Study.

BACKGROUND: Hepatitis B virus (HBV) infection leads to hepatic and extrahepatic manifestations including chronic kidney disease (CKD). However, the association between HBV and CKD is not clear. This study investigated the association between chronic HBV infection and CKD in a nationwide multicenter study. METHODS: A total of 265,086 subjects who underwent health-check examinations in 33 hospitals from January 2015 to December 2015 were enrolled. HBV surface antigen (HBsAg) positive cases (n = 10,048), and age- and gender-matched HBsAg negative controls (n = 40,192) were identified. CKD was defined as a glomerular filtration rate (GFR) < 60 mL/min/1.73 m2 or proteinuria as at least grade 2+ of urine protein. RESULTS: HBsAg positive cases showed a significantly higher prevalence of GFR < 60 mL/min/1.73 m2 (3.3%), and proteinuria (18.9%) than that of the controls (2.6%, P < 0.001, and 14.1%, P < 0.001, respectively). In the multivariate analysis, HBsAg positivity was an independent factor associated with GFR < 60 mL/min/1.73 m2 along with age, blood levels of albumin, bilirubin, anemia, and hemoglobin A1c (HbA1c). Likewise, HBsAg positivity was an independent factor for proteinuria along with age, male, blood levels of bilirubin, protein, albumin, and HbA1c. A subgroup analysis showed that HBsAg positive men but not women had a significantly increased risk for GFR < 60 mL/min/1.73 m2. CONCLUSION: Chronic HBV infection was significantly associated with a GFR < 60 mL/min/1.73 m2 and proteinuria (≥ 2+). Therefore, clinical concern about CKD in chronic HBV infected patients, especially in male, is warranted.

Additional value of diffusion-weighted imaging to evaluate multifocal and multicentric breast cancer detected using pre-operative breast MRI.

OBJECTIVES: To investigate whether diffusion-weighted imaging (DWI) aids pre-operative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) to evaluate additional lesions in breast cancer patients. METHODS: DCE-MRI and DWI were performed on 131 lesions, with available histopathological results. The apparent diffusion coefficient (ADC) of each lesion was measured, and the cut-off value for differentiation between malignant and benign lesions was calculated. A protocol combining the ADC cut-off value with DCE-MRI was validated in a cohort of 107 lesions in 77 patients. RESULTS: When an ADC cut-off value of 1.11 × 10-3 mm2/s from the development cohort was applied to the additional lesions in the validation cohort, the specificity increased from 18.9% to 67.6% (P < 0.001), and the diagnostic accuracy increased from 61.7% to 82.2% (P = 0.05), without significant loss of sensitivity (98.6% vs. 90.0%, P = 0.07). The negative predictive values of lesions in the same quadrant had decreased, as had those of lesions ≥1 cm in diameter. The ADC cut-off value in the validation cohort was 1.05 × 10-3 mm2/s. CONCLUSIONS: Additional implementation of DWI for breast lesions in pre-operative MRI can help to obviate unnecessary biopsies by increasing specificity. However, to avoid missing cancers, clinicians should closely monitor lesions located in the same quadrant or lesions ≥1 cm. KEY POINTS: • DWI can be used to further differentiate lesions during pre-operative cancer staging. • ADC cut-off values were similar in the development and validation cohorts. • DWI improves both PPV and NPV in cases of multicentric lesions. • DWI improves both PPV and NPV in lesions <1 in diameter. • NPVs are decreased in multifocal lesions and lesions ≥1 cm in diameter.

Clinical Outcomes for Endovascular Repair of Thoracic Aortic Disease Using the Seal Thoracic Stent Graft: A Korean Multicenter Retrospective Study.

PURPOSE: To investigate the midterm outcomes of thoracic endovascular aneurysm repair (TEVAR) with the use of the Seal stent graft for four categories of thoracic aortic disease. MATERIALS AND METHODS: This retrospective multicenter study evaluated the records of 216 Korean patients who underwent TEVAR with the Seal stent graft during 2007-2010. The study outcomes were (i) perioperative death, (ii) endoleak, (iii) repeat intervention, (iv) aortic-related death, and (v) all sudden unexplained late deaths. RESULTS: The overall technical success rate was 94% (203 cases), and the disease-specific rates were 97% (88 cases) for aneurysms, 96% (71 cases) for dissections, 82% (32 cases) for traumatic aortic disease, and 100% (12 cases) for intramural hematoma and/or penetrating aortic ulcer. There were 6 acute surgical conversions (2 for aneurysms and 4 for dissections). There were 18 endoleaks, 4 retrograde ascending aortic dissections, and 6 stent graft-induced new entries. The 1-, 3-, and 5-year overall survival rates were 93% ± 3, 90% ± 4, and 90% ± 4, respectively. CONCLUSIONS: TEVAR with the Seal thoracic stent graft provided a high technical success rate and low mortality and complication rates during midterm follow-up. However, additional long-term studies are needed to evaluate the durability and late complications associated with this device.

Combined Therapy of Transcatheter Arterial Chemoembolization and Radiofrequency Ablation versus Surgical Resection for Single 2-3 cm Hepatocellular Carcinoma: A Propensity-Score Matching Analysis.

PURPOSE: To compare therapeutic outcomes of radiofrequency (RF) ablation combined with transcatheter arterial chemoembolization vs surgical resection (SR) for single 2-3 cm hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Seventy patients underwent combined chemoembolization/RF ablation therapy and 84 underwent SR. Local tumor progression (LTP), intrahepatic distant recurrence (IDR), disease-free survival (DFS), and overall survival (OS) rates, as well as major complications and duration of hospital stay, were compared between groups before and after propensity-score matching. RESULTS: LTP and IDR had developed in 9 (12.9%) and 24 (34.3%) patients in the combined treatment group and in 7 (8.3%) and 24 (28.6%) patients in the SR group (P = .262 and P = .252, respectively). The 1-, 3-, 4-, and 5-year DFS rates were similar between groups (82.6%, 53.2%, 53.2%, and 37.6%, respectively, vs 84.5%, 63.6%, 59.2%, and 52.1%, respectively; P = .278), and 1-, 3-, 4-, and 5-year OS rates were also comparable (94.2%, 81.2%, 74.1%, and 59.4%, respectively, vs 95.2%, 86.3%, 84.0%, and 80.3%, respectively; P = .081). After matching (n = 98), LTP, IDR, DFS, and OS rates were still similar (P = .725, P = .826, P = .484, and P = .578, respectively). Major complication rate was not significantly different (2.9% vs. 6.0%; P = .596); however, after matching, major complication rate was higher in SR group (2.0% vs. 6.1%; P < .001). Hospital stays were significantly longer in the SR group (16.6 ± 6.7 d vs 8.5 ± 4.1 d; P < .001). CONCLUSIONS: Before and after matching, there were no significant differences in long-term therapeutic outcomes between combined chemoembolization/RF ablation and SR groups. Therefore, combined chemoembolization/RF ablation therapy may be an alternative treatment for single 2-3 cm HCCs.

Hepatic Parenchymal Heterogeneity as a Marker for Oxaliplatin-Induced Sinusoidal Obstruction Syndrome: Correlation With Treatment Response of Colorectal Cancer Liver Metastases.

OBJECTIVE: The objective of our study was to evaluate the influence of oxaliplatin-based chemotherapy (OBC)-induced hepatic parenchymal heterogeneity detected on contrast-enhanced CT scans on response of liver metastasis. We chose to study hepatic parenchymal heterogeneity on the basis of the assumption that hepatic parenchymal heterogeneity may indicate the presence of chemotherapy-induced sinusoidal obstruction syndrome (SOS). MATERIALS AND METHODS: For this retrospective study, 104 patients with hepatic metastases from colorectal cancer (male-female ratio, 66:38; age range, 20-80 years) who had undergone OBC and serial CT studies were consecutively registered. Two blinded imagers independently scored CT images using a 5-point scale to determine the severity of newly developed hepatic parenchymal heterogeneity after OBC. Subsequently, two radiologists evaluated tumor response to OBC using a 4-point ordinal scale. We performed generalized estimating equation (GEE) analysis using cumulative logits to account for the effect of hepatic parenchymal heterogeneity severity on the cumulative tumor response probability. RESULTS: The interobserver agreements for the severity of hepatic parenchymal heterogeneity were excellent (κ = 0.825). GEE analyses showed that the severity of post-OBC hepatic parenchymal heterogeneity, number of chemotherapy sessions, and presence of other organ metastases were significant predictors of tumor response; these three factors also showed significance in the final GEE model (p < 0.0001 for severity of hepatic parenchymal heterogeneity for both readers; p = 0.011 and 0.010 for the number of chemotherapy sessions for readers 1 and 2; p = 0.046 and 0.012 for the presence of other organ metastases for readers 1 and 2). CONCLUSION: Hepatic parenchymal heterogeneity detected on contrast-enhanced CT of patients with hepatic metastases from colorectal cancer who have undergone OBC may indicate the presence of SOS, and the more severe the SOS, the worse the tumor response of hepatic metastasis to oxaliplatin is expected to be.

Prospero homeobox 1 mediates the progression of gastric cancer by inducing tumor cell proliferation and lymphangiogenesis.

BACKGROUND: Prospero homeobox 1 (PROX1) functions as a tumor suppressor gene or an oncogene in various cancer types. However, the distinct function of PROX1 in gastric cancer is unclear. We determined whether PROX1 affected the oncogenic behavior of gastric cancer cells and investigated its prognostic value in patients with gastric cancer. METHODS: A small interfering RNA against PROX1 was used to silence PROX1 expression in gastric cancer cell lines AGS and SNU638. Expression of PROX1 in gastric cancer tissues was investigated by performing immunohistochemistry. Apoptosis, proliferation, angiogenesis, and lymphangiogenesis were determined by performing the TUNEL assay and immunohistochemical staining for Ki-67, CD34, and D2-40. RESULTS: PROX1 knockdown induced apoptosis by activating cleaved caspase-3, caspase-7, caspase-9, and poly(ADP-ribose) polymerase, and by decreasing the expression of anti-apoptotic proteins Bcl-2 and Bcl-xL. PROX1 knockdown also suppressed tumor cell proliferation. In addition, PROX1 knockdown decreased lymphatic endothelial cell invasion and tube formation and the expression of vascular endothelial growth factor (VEGF)-C and -D and cyclooxygenase (COX)-2. However, PROX1 knockdown only decreased umbilical vein endothelial cell invasion, not tube formation. The mean Ki-67 labeling index and lymphatic vessel density value of PROX1-positive tumors were significantly higher than those of PROX1-negative tumors. However, no significant difference was observed between PROX1 expression and apoptotic index or microvessel density. PROX1 expression was significantly associated with age, cell differentiation, lymph node metastasis, cancer stage, and poor survival. CONCLUSIONS: These results indicate that PROX1 mediates the progression of gastric cancer by inducing tumor cell proliferation and lymphangiogenesis.