Diagnosis and spontaneous healing of asymptomatic renal allograft extra-renal pseudo-aneurysm: A case report.

BACKGROUND: Transplant renal artery stenosis is a relatively frequent vascular complication after transplantation. However, extra-renal pseudo-aneurysms (EPSAs) are rare after transplantation; they can be life-threatening and usually need open surgical repair. We discuss the diagnosis and spontaneous healing of an asymptomatic renal allograft EPSA caused by renal artery anastomotic stenosis, which was diagnosed in a timely manner and managed by conservative treatments. CASE SUMMARY: We present a 37-year-old male patient diagnosed with a renal allograft EPSA caused by renal artery anastomotic stenosis due to multiple atherosclerotic plaques with ultrasonographic examination 6 mo post transplantation. The stenosis rate of 90% and the EPSA were verified by computed tomography angiography. The diagnosis was further confirmed with digital subtraction angiography. Percutaneous transluminal angiography was conducted, and a metallic stent was successfully implanted at the stenosed site of the main renal artery trunk. No further intervention for the EPSA was undertaken due to the difficulty of stenting and the risk of bleeding; regular ultrasonographic follow-ups were recommended. The stenosis was significantly relieved immediately after stent implantation and the EPSA was healed spontaneously by completely filling with hypo-echoic thrombosis 8 mo after stenting. CONCLUSION: Ultrasonography combined with a high-frequency linear probe can detect vascular complications post renal transplantation at an early stage and improve prognosis.

Preoperative serum 25-hydroxyvitamin D3 and the incidence of early pulmonary infection after pediatric living donor liver transplantation.

BACKGROUND: Pulmonary infection is a common complication in pediatric living donor liver transplantation (LDLT) recipients. It has been suggested that vitamin D has a role in immune defense against infection. Therefore, we investigated the effect of preoperative serum 25-hydroxyvitamin D3 (25(OH)D3 ) on the risk of pneumonia in hospitalized patients undergoing LDLT. MATERIALS AND METHODS: This study was a retrospective review of patient records. Fifty consecutive pediatric patients (aged < 14 years) who underwent LDLT from January 2017 to December 2017 were included. Pulmonary infection in the early postoperative period was diagnosed using clinical, radiological, or laboratory criteria. Preoperative serum 25(OH)D3 level, demographic characteristics, primary diagnosis, ascites, time to extubation, length of intensive care unit stay, and perioperative laboratory values were recorded. Vitamin D deficiency, insufficiency, and sufficiency were defined as a serum 25(OH)D3 concentration of less than 10, 10 to 20, and more than 20 ng/mL, respectively. Associations between serum 25(OH)D3 levels and pulmonary infection were analyzed. RESULTS: Of 50 pediatric patients who underwent LDLT, 19 (38%) developed pulmonary infections in the early postoperative period. The mean serum 25(OH)D3 level in these subjects was 18.7 ± 17.2 ng/mL (range, 3.0-70.0 ng/mL). Twenty patients (40%) had severe vitamin D deficiency (<10 ng/mL). The mean serum 25(OH)D3 level was significantly decreased (9.3 ± 7.4 vs 24.5 ± 19.1 ng/mL, P = .002) in patients with pulmonary infection compared with those without pulmonary infection. Serum 25(OH)D3 level as a continuous variable (odds ratio [OR], 0.90, 95% confidence interval [CI], 0.84-0.97, P = .008) and a classification variable (≤10 ng/mL) (OR, 7.42, 95% CI, 2.06-26.79, P = .002) were significantly associated with pulmonary infection in univariate analysis. After adjusting for other significant predictors (age, weight, and pediatric end-stage liver disease score), severe 25(OH)D3 deficiency at presentation was independently associated with a higher risk of developing pulmonary infection in the early postoperative period (OR, 5.11, 95% CI, 1.30-20.16, P = .02). CONCLUSIONS: 25(OH)D3 deficiency is common and inversely correlated with pulmonary infection within the first month after pediatric LDLT. Our results indicate that preoperative serum 25(OH)D3 deficiency is a potential biomarker for early pulmonary infection after pediatric LDLT.

Perioperative characteristics and management of liver transplantation for isolated methylmalonic acidemia-the largest experience in China.

BACKGROUND: There are few detailed consensus and guidelines on perioperative clinical characteristics of liver transplantation (LT) in patients with methylmalonic acidemia (MMA). This retrospective study investigated details of the clinical course and individualized treatment plan of the center with largest experience in China. METHODS: A total of 7 MMA patients undergoing LT in Beijing Friendship Hospital from June 2013 to December 2017 were enrolled in the study, whose clinical data (clinical characteristics, laboratory findings, chronological changes in urine MMA levels, treatment, etc.) during perioperative period were analyzed retrospectively. All the patients received strict postoperative management. RESULTS: All the 7 cases were confirmed to have isolated MMA, among which, 3 cases received living donor liver transplantation (LDLT), 4 cases received deceased donor liver transplantation (DDLT). A wild fluctuate of metabolic condition was observed within the first few days after surgery and two weeks after LT, the mean base excess of blood value (BE-B) restored to normal whereas plasma bicarbonate (HCO3 -) was still below normal value even with intermittent sodium bicarbonate correction. It also showed marked reduction in propionylcarnitine (C3) and C3/C2 level and the mean urine MMA by gas chromatography-mass spectrometry (GC-MS) was reduced by 81.7% (P<0.01) but remained >72× higher than upper limit of normal. The metabolism-correcting medications were administered as before. The renal function of one case with renal insufficiency before LT (serum creatinine rising) maintained stable by adjusting the immunosuppressive regimen during the observation period. All patients survive to date. CONCLUSIONS: LT is an effective treatment to prevent metabolic crisis, but patients with MMA tend to be metabolically fragile even after surgery. During perioperative period, close monitoring should be given for acidosis episodes so as to implement sodium bicarbonate correction. Metabolism-correcting medications are still needed. Special immunosuppressive regimen is an effective way of maintaining renal function for those with kidney dysfunction.

Multimodality-imaging manifestations of primary renal-allograft synovial sarcoma: First case report and literature review.

BACKGROUND: Primary renal synovial sarcoma (PRSS) is an extremely rare tumor with a poor prognosis. Its imaging and immunohistochemical characteristics may overlap with other renal tumors, which renders its early diagnosis in a dilemma. The diagnosis of primary renal synovial sarcoma requires histopathology and the confirmation of SYT-SSX gene fusion using molecular techniques. Cases of primary renal synovial sarcoma have been previously reported in the literature. However, to our knowledge, primary renal allograft synovial sarcoma was never described. CASE SUMMARY: A 43-year-old male patient who underwent kidney transplantation 9 months ago came to our hospital for regular follow-up. Traditional ultrasonography revealed multiple hypo-echo neoplasms in the renal allograft. Contrast-enhanced computed tomography (CECT) showed slightly hyper-density masses with slow homogeneous enhancement. Ultrasound-guided biopsy was conducted for accurate pathological diagnosis. The neoplasms were diagnosed as synovial sarcoma by pathological, immunohistochemical, and genetic analyses. Positron emission tomography/CT showed no evidence of metastasis. At approximately one week post biopsy, contrast-enhanced ultrasound was conducted to eliminate active hemorrhage. One month later, CECT showed that the biggest neoplasm grew from 3.3 cm to 5.7 cm in diameter. Parametric imaging was conducted with SonoLiver CAP to conduct further quantitative analysis, which showed that the enhancement pattern was heterogeneous hyper-vascular enhancement. Radical surgical resection of the whole renal allograft and ureter was conducted without additional adjuvant chemotherapy or external radiotherapy. Anlotinib was chosen for targeted therapy with a good response. CONCLUSION: We propose multimodality imaging for accurate diagnosis of renal allograft synovial sarcoma especially when it is formed by spindle-shaped cells.

A New Approach to Accomplish Intraoperative Cholangiography in Left Lateral Segmentectomy of Living Liver Donation.

BACKGROUND There are 2 main methods of bile duct division in harvesting left lateral segment of a living donor: 1) by intraoperative cholangiography through cystic duct with cholecystectomy, or 2) by direct vision with preoperative magnetic resonance cholangiopancreatography. Here, we present a new approach to cholangiography by using the bile duct stump of the fourth liver segment (B4 stump) to achieve left lateral segmentectomy in pediatric living donor liver transplantation. MATERIAL AND METHODS This was a prospective study of 221 living donors who had undergone intraoperative cholangiography via the B4 stump in the course of left lateral segmentectomy. We collected and analyzed the clinical data, including the success rate of cholangiography by catheterizing the B4 stump; the associated time cost; the classification of the donor liver's biliary anatomy; the number of bile duct orifices on the graft side; and postoperative complications involving the biliary tract. RESULTS We were successful in catheterizing B4 stumps in all 221 patients. The mean time cost of these procedures was 7.21±3.62 minutes. Variations in the confluence of the right and left lobes were found in 58 patients (26.24%). Overall, sludge was detected in 18 cases (8.14%), gallstones were found in 3 patients (1.36%), and a polypoid gallbladder lesion was found in 1 patient (0.45%). There were 11 cases (4.98%) of bile leakage; no biliary strictures were found in the donors. CONCLUSIONS Intraoperative cholangiography via the B4 stump is an alternative procedure for living donors who undergoes left lateral segmentectomy.

First case of cross-auxiliary double domino donor liver transplantation.

We report a case of double domino liver transplantation in a 32-year-old woman who was diagnosed with familial amyloid polyneuropathy (FAP) and liver dysfunction. A two-stage surgical plan was designed, and one domino graft was implanted during each stage. During the first stage, an auxiliary domino liver transplantation was conducted using a domino graft from a 4-year-old female child with Wilson's disease. After removing the right lobe of the FAP patient's liver, the graft was rotated 90 degrees counterclockwise and placed along the right side of the inferior vena cava (IVC). The orifices of the left, middle, and right hepatic veins were reconstructed using an iliac vein patch and then anastomosed to the right side of the IVC. Thirty days later, a second domino liver graft was implanted. The second domino graft was from a 3-year-old female child with an ornithine carbamyl enzyme defect, and it replaced the residual native liver (left lobe). To balance the function and blood flow between the two grafts, a percutaneous transcatheter selective portal vein embolization was performed, and "the left portal vein" of the first graft was blocked 9 mo after the second transplantation. The liver function indices, blood ammonia, and 24-h urinary copper levels were normal at the end of a 3-year follow-up. These two domino donor grafts from donors with different metabolic disorders restored normal liver function. Our experience demonstrated a new approach for resolving metabolic disorders with domino grafts and utilizing explanted livers from children.

Role of contrast-enhanced ultrasound in the differentiation of high- and low-grade urothelial carcinoma.

OBJECTIVE: To investigate the role of contrast-enhanced ultrasound in the differential diagnosis of high- and low-grade urothelial carcinoma. METHODS: The radiological data of 96 patients with urothelial carcinomas who had undergone gray-scale contrast-enhanced ultrasound from August 2010 to April 2011 were analyzed retrospectively. Pathological examination demonstrated that the tumors were high-grade in 55 cases (high-grade group) and low-grade in 41 cases (low-grade group). The dynamic images were analyzed by time-intensity curve, and the arrival time (AT), peak intensity (PI), time to peak (TTP), and washout time (WT) were measured. The enhancement patterns of different urothelial carcinomas were analyzed. RESULTS: Both PI (P=0.005) and WT (P=0.002) were significantly higher in high-grade group than in low-grade group, whereas AT (P=0.374) and TTP (P=0.386) showed no significant difference between these two groups. In the high-grade group, 47 cases (85.5%) were identified as fast wash-in and slow wash-out; in the low-grade group, 35 (85.4%) were identified as fast wash-in and fast wash-out. When the enhancement pattern was used as a diagnostic indicator for differentiating urothelial carcinomas, the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 85.5%, 90.2%, 87.5%, 92.2%, and 82.2% for high-grade tumor and 85.4%, 90.9%, 88.5%, 87.5%, and 89.3% for low-grade tumor. CONCLUSIONS: Different grade urothelial carcinomas show different enhancement finding on contrast-enhanced ultrasound. The enhancement pattern can serve as an important diagnostic indicator.

[Establishment of a nomogram for predicting positive repeat prostate biopsy in Chinese men].

OBJECTIVE: To develop a nomogram for predicting the probability of prostate cancer at transrectal ultrasound-guided repeat prostate biopsy in Chinese men. METHODS: We performed repeat biopsy for 170 patients with benign prostate diseases diagnosed on the first biopsy, and analyzed the correlation of positive repeat biopsy with age, prostate volume, PSA, free-to-total PSA (f-PSA/t-PSA), PSA velocity, PSA density, results of digital rectal examination (DRE) and previous histology. We entered the variables stepwise into logistic regression models, and established a nomogram for the risk score on the probability of positive repeat biopsy, whose predictive value was assessed by receiver operating characteristic (ROC) analysis. RESULTS: Prostate cancer was detected in 31.8% of the repeat biopsies (54/170). The most accurate predictive nomogram comprised age, PSA, f-PSA/t-PSA, PSA velocity, prostate volume, DRE and previous prostatic intraepithelial neoplasia (PIN) findings. The nomogram exhibited a high predictive value, with the area under the ROC curve (AUC) of 82.4%, significantly greater than that of the prediction based on PSA density (AUC: 66.9%), prostate volume (AUC: 72.6%), PSA velocity (AUC: 69.6%), f-PSA/t-PSA (AUC: 69.3%), or DRE (AUC: 58.5% ) alone. CONCLUSION: The nomogram is an accurate multi-variable predicting tool to determine the probability of positive repeat prostate biopsy.

Clinical utility of three-dimensional contrast-enhanced ultrasound in the differentiation between noninvasive and invasive neoplasms of urinary bladder.

OBJECTIVES: The purpose of this study was to evaluate the effectiveness of three-dimensional contrast-enhanced ultrasound in differentiating invasive and noninvasive neoplasms of urinary bladder. METHODS: A total of 60 lesions in 60 consecutive patients with bladder tumors received three dimensional ultrasonography, low acoustic power contrast enhanced ultrasonography and low acoustic power three-dimensional contrast-enhanced ultrasound examination. The IU22 ultrasound scanner and a volume transducer were used and the ultrasound contrast agent was SonoVue. The contrast-specific sonographic imaging modes were PI (pulse inversion) and PM (power modulation). The three dimensional ultrasonography, contrast enhanced ultrasonography, and three-dimensional contrast-enhanced ultrasound images were independently reviewed by two readers who were not in the images acquisition. Images were analyzed off-site. A level of confidence in the diagnosis of tumor invasion of the muscle layer was assigned on a 5° scale. Receiver operating characteristic analysis was used to assess overall confidence in the diagnosis of muscle invasion by tumor. Kappa values were used to assess inter-readers agreement. Histologic diagnosis was obtained for all patients. RESULTS: Final pathologic staging revealed 44 noninvasive tumors and 16 invasive tumors. Three-dimensional contrast-enhanced ultrasound depicted all 16 muscle-invasive tumors. The diagnostic performance of three-dimensional contrast-enhanced ultrasound was better than those of three dimensional ultrasonography and contrast enhanced ultrasonography. The receiver operating characteristic curves were 0.976 and 0.967 for three-dimensional contrast-enhanced ultrasound, those for three dimensional ultrasonography were 0.881 and 0.869, those for contrast enhanced ultrasonography were 0.927 and 0.929. The kappa values in the three dimensional ultrasonography, contrast enhanced ultrasonography and three-dimensional contrast-enhanced ultrasound for inter-reader agreements were 0.717, 0.794 and 0.914. CONCLUSION: Three-dimensional contrast-enhanced ultrasound imaging, with contrast-enhanced spatial visualization is clinical useful for differentiating invasive and noninvasive neoplasms of urinary bladder objectively.

Differentiation of prostate cancer from benign lesions using strain index of transrectal real-time tissue elastography.

OBJECTIVE: This study was to assess the diagnostic value of strain index (SI) for transrectal real-time tissue elastography (TRTE) on differentiating malignant from benign lesions in the prostate peripheral zone. METHODS: 83 patients suspected of having prostate cancer (PCa) underwent transrectal ultrasonography (TRUS) and TRTE examinations. The lesions in the prostate peripheral zone detected by TRTE were set as the regions of interest (ROI) for strain ratio (SR) measurement (SRA). The moderate texture tissues without lesion were set as the reference ROI for SR measurement (SRB). Then, SI (SRB/SRA) of total lesions (ASI) and local lesion (PSI) were calculated, and the diagnostic values of ASI and PSI on differentiating benign from malignant lesions were assessed respectively. RESULTS: The range of PSI was 2.23-67.21 (29.97 ± 15.58) in malignant tumors and 0. 4-43.6 (7.79 ± 8.75) in benign lesions (AUC=0.90), while the range of ASI was 2.84-47.9 (8.38 ± 12.20) in malignant tumors and 0.4 -2.79 (5.85 ± 7.29) in benign lesions (AUC=0.62). There was significant difference of PSI values between the benign and malignant lesions (P<0.01). At the cutoff value of 17.44, PSI yielded the highest sensitivity (74.5%) and specificity (83.3%) for discriminating PCa from benign lesions. The capability of PSI in the diagnosis of PCa improved with the increase of Gleason scores. CONCLUSION: PSI is one of the elasticity parameters obtained easily by TRTE, it can provide more information in the differentiation of prostate peripheral zone lesions.

The contribution of strain patterns in characterization of prostate peripheral zone lesions at transrectal ultrasonography.

BACKGROUND: Elasticity is an important characteristic of tissue. During an elastography examination, various strain images of lesions are observed, and a suitable classification of strain patterns (SP) may provide vital diagnostic information about lesions. Numerous studies have shown that ultrasound elastography can improve the detection of prostate cancer, but the diagnostic value of SP classification has not yet been fully evaluated. PURPOSE: To investigate the contribution of SP on the characterization of prostate peripheral zone lesions by transrectal real-time tissue elastography (TRTE) in combination with conventional transrectal ultrasonography (TRUS). MATERIAL AND METHODS: One hundred and seventy-one patients with suspected prostate cancer underwent TRUS and TRTE examinations. The SPs of the suspicious lesions were classified into five scores by TRTE according to the degree and distribution of strain. All findings were confirmed by transrectal systematic 12-core biopsies and targeted biopsies for suspicious areas detecting by TRUS and/or TRTE. RESULTS: One hundred and forty-eight of 171 patients had high-quality TRTE imaging and were included into the study. When a cut-off point of SP score III was used, the area under the receiver-operating characteristic curve (AUC) was, respectively, 0.75 (95% CI: 0.67-0.83), 0.85 (95% CI: 0.78-0.91) and 0.84 (95% CI: 0.77-0.91) for the diagnosis of prostate cancer by TRUS, TRTE and TRTE + TRUS. A linear tendency of SP and Gleason scores was observed in scores III-V. The detection rate of prostate cancer using TRTE-targeted biopsy (75.8%) was significantly higher than that of systematic 12-core biopsy plus TRUS-targeted biopsy (14.5%) (P = 0.00). CONCLUSION: This study suggests the significant contribution of SP on characterization of prostate peripheral zone lesions and the improvement of TRTE-targeted biopsy on detection of prostate cancer.

[Development of a nomogram for predicting positive initial prostate biopsy among Chinese patients].

OBJECTIVE: To develop a predictive nomogram for predicting the prostate carcinoma among Chinese population. METHODS: Totally 556 Chinese male patients who had undergone an initial prostate biopsy in our hospital from July 2004 to February 2009 were enrolled in this study. Variables including age, volume, prostate specific antigen (PSA) level, and free PSA (f-PSA)/total PSA (t-PSA) were collected. Logistic regression analysis was performed to estimate the relative risk. Regression equation was established for variables via stepwise regression, via which a nomogram for assessing the positive biopsy results was established, and then the predictive value of this nomogram was evaluated using receiver area under curve (ROC) analysis. RESULTS: Of these 556 patients, cancer was detected in 205 patients (36.87%) via biopsies. Univariate analysis showed that age, prostate volume, PSA levels, and f-PSA/t-PSA were the influencing factors of the nomogram. The risk model performed well in an independent sample, with an AUC(ROC) of 0.8767, which was significantly larger than that of the prediction based on age (AUC(ROC) : 0.6397), prostate volume (AUC(ROC) : 0.7255), PSA (AUC(ROC) : 0.7111), or f-PSA/t-PSA (AUC(ROC) : 0.6973) alone. CONCLUSION: A preliminary nomogram with high predictive value for Chinese population was successfully established.

[Transrectal ultrasound-guided systematic 12-core biopsy of the prostate improves prostate cancer detection].

OBJECTIVE: To evaluate transrectal ultrasound-guided systematic 12-core biopsy of the prostate for the detection and characterization of prostate cancer in different age and prostate specific antigen (PSA) groups. METHODS: Totally 210 patients were divided into four age groups (< or = 59 yr, 60-69 yr, 70-79 yr, and > or = 80 yr) and five PSA groups (0-4 microg/L, 4.1-10 microg/L, 10.1 -20 microg/L, 20.1-50 microg/L, and > 50 microg/L), and underwent transrectal ultrasound-guided systematic 12-core biopsy of the prostate at various sites for detecting prostate cancer. Clinical data and the results of various biopsy schemes were analyzed and compared. RESULTS: Ninety-one cases of prostate cancer were detected among the 210 patients, with a total detection rate of 43.3%, and the percentage was higher with the increase of age and PSA level. Larger and higher-grade tumors were associated with older age and higher PSA level, and higher detection rates were related to laterally directed and apical biopsies. The 12-core biopsy outperformed other biopsy schemes in detecting prostate cancer in patients under 60 years of age and with PSA < 20 microg/L. CONCLUSION: The 12-core biopsy scheme can make up for the inadequacy of sextant biopsy in detecting prostate cancer, and less influenced by the age and PSA level of the patients. Generally larger and higher-grade tumors are associated with older age and higher PSA level.

[Diagnostic value of strain index in prostate peripheral zone lesions by real time tissue elastography].

OBJECTIVE: To investigate the value of strain index (SI) by transrectal real-time tissue elastography (TRTE) for differentiation of the prostate peripheral zone lesions. METHODS: Totally 83 patients with suspected prostate cancer underwent the quantitative analysis by TRTE examination. The SI of total lesions (ASI) and peak elasticity in lesion (PSI) were calculated, and the pathologic findings were compared. Then the values of ASI and PSI in the differential diagnosis of prostate lesions were assessed. The influence of Gleanson scores on SI was evaluated. RESULTS: The area under the Receiver Operating Characteristic curves (or ROC curves) of ASI and PSI were 0.62 (P=0.06) and 0.92 (P=0.00) respectively for the differential diagnosis of prostate peripheral lesions. When a cutoff point of 17.44 was used,PSI had a sensitivity of 74.5% and a specificity of 83.3%. Gleason scores showed no significant difference between PSIü 17.44 group and PSIþ17.44 group ( P>0.05). CONCLUSION: PSI is helpful for the differential diagnosis of prostate peripheral zone lesions.