Validation of the Diagnostic Criteria for IgG4-Related Periaortitis/Periarteritis and Retroperitoneal Fibrosis (IgG4PA/RPF) 2018, and Proposal of a Revised 2023 Version for IgG4-Related Cardiovascular/Retroperitoneal Disease.

BACKGROUND: In 2018, diagnostic criteria were introduced for IgG4-related periaortitis/periarteritis and retroperitoneal fibrosis (PA/RPF). This study assessed the existing criteria and formulated an improved version.Methods and Results: Between August 2022 and January 2023, we retrospectively analyzed 110 Japanese patients diagnosed with IgG4-related disease (IgG4-RD) involving cardiovascular and/or retroperitoneal manifestations, along with 73 non-IgG4-RD patients ("mimickers") identified by experts. Patients were stratified into derivation (n=88) and validation (n=95) groups. Classification as IgG4-RD or non-IgG4-RD was based on the 2018 diagnostic criteria and various revised versions. Sensitivity and specificity were calculated using experts' diagnosis as the gold standard for the diagnosis of true IgG4-RD and mimickers. In the derivation group, the 2018 criteria showed 58.5% sensitivity and 100% specificity. The revised version, incorporating "radiologic findings of pericarditis", "eosinophilic infiltration or lymphoid follicles", and "probable diagnosis of extra-PA/-RPF lesions", improved sensitivity to 69.8% while maintaining 100% specificity. In the validation group, the original and revised criteria had sensitivities of 68.4% and 77.2%, respectively, and specificities of 97.4% and 94.7%, respectively. CONCLUSIONS: Proposed 2023 revised IgG4-related cardiovascular/retroperitoneal disease criteria show significantly enhanced sensitivity while preserving high specificity, achieved through the inclusion of new items in radiologic, pathological, and extra-cardiovascular/retroperitoneal organ categories.

Usefulness of intratumoral perfusion analysis for assessing biological features of non-functional pancreatic neuroendocrine neoplasm.

PURPOSE: Here, we evaluated the usefulness of intratumoral perfusion analysis using preoperative contrast-enhanced CT (E-CT) to assess biological features of non-functional pancreatic neuroendocrine neoplasms (NF-PanNENs). METHODS: We retrospectively studied 44 patients who underwent curative surgery for NF-PanNENs. We used preoperative E-CT with compartment model analysis to calculate the tumor perfusion parameters K1 (inflow rate constant), 1/k2 (mean transit time), and K1/k2 (distribution volume). We assessed the association between perfusion parameters and biological features of NF-PanNENs, including the WHO classification tumor histopathological grade and prognosis after surgery. RESULTS: Patients in this study had a neuroendocrine tumor (NET) G1 (n = 32) or NET G2 (n = 12). Neither NET G3 or NEC tumors were observed. Among perfusion parameters, K1 was the most accurate predictor of the high-grade tumor (AUC: 0.726). K1-low (< 0.028 s-1) was significantly associated with large tumors (≥ 20 mm) (p = 0.022), high mitotic index (p = 0.017), high Ki-67 index (p = 0.004), and lymphatic invasion (p = 0.025). Synchronous extra-pancreatic metastasis, including lymph node metastasis or liver metastasis, more frequently developed in K1-low patients than in K1-high patients (29% vs 4%, p = 0.025). Disease-free survival of patients with a K1-low tumor was poorer than that of patients with a K1-high tumor (p = 0.005). Furthermore, no patient with a K1-high tumor developed recurrence after initial surgery. CONCLUSION: The perfusion parameters obtained using E-CT were significantly associated with biological features and prognosis of NF-PanNENs.

Rapid identification of source of delayed hemobilia following endoscopic metallic stenting for malignant biliary obstruction.

Delayed hemobilia, a rare but potentially fatal complication of endoscopic metallic stenting for malignant biliary obstruction, requires prompt identification of the source of bleeding and subsequent embolization. However, hemobilia is characteristically intermittent, and computed tomography (CT) often fails to show pseudoaneurysms or extravasations. In particular, because the posterior superior pancreaticoduodenal artery (PSPDA) runs alongside the common bile duct for its whole length, it is readily obscured by metallic artifacts in that duct, such as stents, making identification of the source of bleeding by CT difficult. We have encountered three patients with delayed hemobilia from the PSPDA following endoscopic biliary stenting for malignant biliary obstruction in whom no extravasation or pseudoaneurysms were detected by contrast-enhanced CT during bleeding. However, when we identified that the PSPDA had a smaller diameter than in previous CTs in all three cases, we suspected that the PSPDA was the source of the bleeding. No extravasation or pseudoaneurysms were detected with celiac arteriography or superior mesenteric arteriography; however, extravasation and pseudoaneurysms were detected by direct PSPDA angiography. Hemostasis was achieved through embolization. Detecting a large decrease in the diameter of the PSPDA on contrast-enhanced CT during biliary bleeding may help to identify the source of that bleeding.

Impact of upgraded radiotherapy system on outcomes in postoperative head and neck squamous cell carcinoma patients.

Background: This study was performed to evaluate the impact of upgrade of radiotherapy system, including launch of intensity-modulated radiation therapy (IMRT), on the therapeutic outcomes. Materials and methods: Patients with head and neck (H&N) squamous cell carcinoma (SCC) who underwent postoperative radiotherapy at our hospital between June 2009 and July 2019 were retrospectively reviewed. In July 2014, we converted the radiotherapy technique for these patients from a 3-dimensional conformal radiotherapy (3D-CRT) to IMRT, along with the adoption of a meticulous planning policy and a few advanced procedures, including online imaging guidance. Results: A total of 136 patients (57 treated with the previous system and 79 treated with the upgraded system) were reviewed. There were significantly more patients with extracapsular extension in the upgraded-system group than the previous-system group (p = 0.0021). There were significantly fewer patients with ≥ Grade 2 acute and late adverse events in the upgraded-system group than the previous-system group. The differences in progression-free survival (PFS), distant metastasis-free survival (DFFS), locoregional progression-free survival (LRPFS), and overall survival (OS) between the two groups were not statistically significant (p = 0.8962, 0.9926, 0.6244, and 0.4827, respectively). Multivariate analysis revealed that the upgrade had neither positive nor negative impact on survival outcomes. Extracapsular extension was independently associated with decreased LRPFS and OS (p = 0.0499 and 0.0392, respectively). Conclusions: The IMRT-centered upgrade was beneficial for the postoperative patients with H&N SCC, because survival outcomes were sustained with less toxicities.

The peritumoral hypointense rim around hepatocellular carcinoma on T2*-weighted magnetic resonance imaging: radiologic-pathologic correlation.

BACKGROUND: A peritumoral hypointense rim (PTHR) is sometimes observed around hepatocellular carcinoma (HCC) on T2*-weighted images (T2*WIs). We aimed to investigate the association between the PTHR and histopathologic findings on T2*WIs. METHODS: We assessed the presence of a PTHR on T2*WIs in 39 pathologically proven HCCs from April 2012 to December 2013. Prussian blue staining was performed, and iron deposition was evaluated by semiquantitative and quantitative methods. Optical density was used in the quantitative methods. The associations between a PTHR on T2*WI and histopathologic peritumoral or background liver iron deposition were analyzed. RESULTS: A PTHR on T2*WI was observed in 23 of 39 (59%) HCCs. There was no significant difference in the histopathologic fibrous capsule findings (P = 0.394). In the semiquantitative methods, both peritumoral and background liver iron deposition grade were significantly higher in HCCs with a PTHR compared with HCCs without a PTHR (P < 0.001). The mean optical density in HCCs with a PTHR was significantly higher compared with HCCs without a PTHR, in the quantitative peritumoral (42,244.1 ± 20,854.9 vs. 18,739.1 ± 12,258.7, respectively; P < 0.001) and background liver iron deposition analyses (35,554.7 ± 19,854.8 vs. 17,292.4 ± 11,605.8, respectively; P < 0.001). Tumor size (P = 0.005), etiology (P = 0.001), and degree of fibrosis (P = 0.042) were significantly associated with the presence of a PTHR. CONCLUSIONS: A PTHR in HCCs on T2*WIs was strongly associated with peritumoral iron deposition in the iron-deposited background liver but not with the fibrous capsule.

Usefulness of the 'cosmos pattern' for differentiating between cervical gastric-type mucin-positive lesions and other benign cervical cystic lesions in magnetic resonance images.

AIM: To evaluate the usefulness of the 'cosmos pattern' (CP) on magnetic resonance (MR) images for differentiating between gastric-type mucin-positive lesions (GMPL) and gastric-type mucin-negative lesions (GMNL). METHODS: This study included 131 patients with clinical suspicion of lobular endocervical glandular hyperplasia (LEGH) who underwent pelvic MR imaging and a Pap smear and/or latex agglutination assay. Differences in MR findings, such as cyst and solid component patterns, cervical location and T1-weighted image (T1WI) signal intensity, were compared between GMPL and GMNL. The diagnostic performances of the findings were assessed. RESULTS: The frequencies of CP (63.1%), upper part (UP) lesions (72.3%) and hypointense area compared with the cervical stroma on T1WI (61.3%) were significantly greater in GMPL than in GMNL (P < 0.05). The sensitivity, specificity, positive predictive value, negative predictive value and odds ratio of the CP for diagnosis of GMPL were 63.1%, 87.9%, 83.7%, 70.7% and 12.4, respectively. In GMNL, a 'macrocystic pattern' was observed in 65.2% of patients; an isointense or hyperintense area on T1WI was observed in 86.4% of patients. The sensitivity was highest (90.8%) when one or more of the following were observed: CP, UP lesion, or hypointense area on T1WI. The specificity was highest (95.5%) when the CP was observed as a hypointense area on T1WI. CONCLUSION: The CP is a highly specific finding for diagnosis of GMPL. If the CP is observed as a hypointense area compared with the cervical stroma on T1WI, GMPL (i.e., LEGH or gastric-type mucinous carcinoma) should be strongly suspected.

Pseudohypoxic brain swelling and secondary hydrocephalus with pseudomeningocele after lumbar surgery: a case report.

BACKGROUND: Postoperative intracranial complications are rare in spine surgery not including cranial procedures. We describe an uncommon case of pseudohypoxic brain swelling (PHBS) and secondary hydrocephalus after transforaminal lumbar interbody fusion (TLIF) presenting as impaired consciousness and repeated seizures. CASE PRESENTATION: A 65-year-old man underwent L4-5 TLIF for lumbar spondylolisthesis and began experiencing generalized seizures immediately postoperatively. Computed tomography (CT) revealed diffuse cerebral edema-like hypoxic ischemic encephalopathy. He was transported to our hospital, at which time epidural drainage was halted and anti-edema therapy was commenced. His impaired consciousness improved. However, he suffered secondary hydrocephalus due to continuous bleeding from a dural defect and spinal epidural fluid collection 3 months later. Following the completion of dural repair and insertion of a ventriculoperitoneal shunt, his neurologic symptoms and neuroimaging findings improved significantly. CONCLUSIONS: PHBS can be considered in patients with unexpected neurological deterioration following lumbar spine surgery even with the absence of documented durotomy. This might be due to postoperative intracranial hypotension-associated venous congestion, and to be distinguished from the more common postoperative cerebral ischemic events-caused by arterial or venous occlusions-or anesthetics complications.

[Examination of Gd-EOB-DTPA Liver Dynamic Contrast-enhanced MRI Using Radial VIBE with k-space Weighted Image Contrast Method].

Dynamic contrast-enhanced magnetic imaging (DCE-MRI) is a useful method for detection and diagnosis of liver lesions. However, DCE-MRI using Gd-EOB-DTPA has some problems with arterial phase images. Radial volumetric imaging breath-holding examination (r-VIBE) with k-space weighted image contrast reconstruction (KWIC), which is a modification of Cartesian VIBE (c-VIBE), is a new 3D-gradient echo sequence with a number of advantages compared with c-VIBE, including lower motion sensitivity. This study was performed to evaluate image contrast, blurring, and temporal phase division effects of r-VIBE in comparison with c-VIBE. Image contrast using diluted Gd-EOB-DTPA aqueous solution showed no significant difference between r-VIBE and c-VIBE. Imaging was performed with r-VIBE and c-VIBE during injection of a Gd-EOB-DTPA solution into a serpentine tube. r-VIBE showed a smaller half-width of the signal intensity profile of the tube and less image artifacts by blurring when compared to c-VIBE. The arrival times and durations of the maximum signal strengths of r-VIBE and c-VIBE images during injection of Gd-EOB-DTPA solution into the tube were almost identical. r-VIBE improved the temporal resolution without degradation of liver DCE-MRI using Gd-EOB-DTPA.

Comparison of the chemokine profiles in the bronchoalveolar lavage fluid between IgG4-related respiratory disease and sarcoidosis: CC-chemokine ligand 1 might be involved in the pathogenesis of sarcoidosis.

BACKGROUND: We previously reported that the cytokine profiles in the bronchoalveolar lavage fluid (BALF) of IgG4-related respiratory disease (IgG4-RRD) more closely resemble the T-helper (Th) 2 response than sarcoidosis. The present study aimed to assess the chemokines in the BALF of IgG4-RRD and sarcoidosis in order to evaluate any possible associations between these chemokines and other markers. METHODS: We examined 12 chemokines using a MILLIPLEX® MAP Kit (Millipore, Darmstadt, Germany) in the same BALF samples of the same 44 patients (IgG4-RRD, n = 11; sarcoidosis, n = 33) in which we had previously evaluated the cytokines. RESULTS: The levels of CC-chemokine ligand (CCL)26 in the BALF of IgG4-RRD patients (median 24.5, range 3.1-401.1 pg/mL) were significantly higher than those in the BALF of sarcoidosis patients (median 3.1, range 3.1-155.6 pg/mL, p < 0.05). Interestingly, the BALF levels of CCL1 in the sarcoidosis patients (median 13.1, range 0.1-106.9 pg/mL) were significantly higher than those of the IgG4-RRD patients (median 9.8, range 0.1-14.7 pg/mL, p < 0.05). Furthermore, the CCL1 levels in the BALF were correlated with the total cell count (ρ = 0.539, p < 0.001), lymphocyte fraction (R = 0.406, P < 0.05), lymphocyte count (R = 0.686, P < 0.001), TNF-α level, (R = 0.748, P < 0.001), and IL-2 level (R = 0.757, P < 0.001) in the BALF of sarcoidosis patients. CONCLUSIONS: CCL1 might reflect disease activity and its involvement in the pathogenesis of sarcoidosis might be more closely related to Th1 than to Th2.

IgG4-related periaortitis/periarteritis: An under-recognized condition that is potentially life-threatening.

Periaortitis and periarteritis are one of the clinical features of IgG4-related disease. Such vascular manifestations are reported to be present in 10-30% of overall IgG4-related disease, and they may also appear as an isolated lesion of IgG4-related disease. As other types of large vessel vasculitis, IgG4-related vasculitis may cause significant clinical consequences. On the other hand, the diagnosis of IgG4-related periaortitis/periarteritis seems to have been made on the basis of different diagnostic criteria in reported studies; thus far, difficulty seems to be present in assessing the true frequency of the disease as well as determining the optimal therapeutic strategy. In this review, in addition presenting the clinical and pathological features of IgG4-related periaortitis/periarteirtis, we would like to discuss on what kind of points should be resolved for the better understanding of vascular involvement of IgG4-related disease in terms of diagnosis and treatment.

Compartment model analysis of intravenous contrast-enhanced dynamic computed tomography in hepatic hemodynamics: A validation study using intra-arterial contrast-enhanced computed tomography.

AIM: To verify the utility of the 2-in-1-out-compartment model analysis (CMA) of intravenous contrast-enhanced dynamic computed tomography (IV-CT) for evaluating hepatic arterial and portal venous flow using intra-arterial contrast-enhanced CT (IA-CT). METHODS: We retrospectively evaluated 49 consecutive patients who underwent IV-CT and were radiologically or histologically diagnosed as having hepatic malignant lesion (51 classical hepatocellular carcinomas [HCC], 4 early HCC, 3 cholangiolocellular carcinomas, 1 mixed HCC, 3 cholangiocellular carcinomas). As a gold standard for hepatic arterial and portal blood flows, we defined the normalized enhancement in CT values on CTAP (nCTAP) and CTHA (nCTHA). The hepatic arterial (k1a ) and portal venous inflow velocity (k1p ) constants in hepatic lesions and surrounding liver parenchyma were obtained from the CMA of IV-CT with various outflow velocity constant (k2 ) limits using the nonlinear least square method. The correlation coefficient between the normalized enhancement in IA-CT and CMA of IV-CT was statistically evaluated according to various k2 limits. RESULTS: The highest mean correlation coefficient between k1a and nCTHA (r = 0.65, P < 0.0001) was observed when k2 ≦0.035. The highest mean correlation coefficient between k1p and nCTAP (r = 0.69, P < 0.0001) was observed when k2 ≦0.045. The decrease in correlation coefficient was significant when the upper k2 limit was lower than 0.03 or higher than 0.07 compared to the best mean correlation coefficient (P < 0.05). CONCLUSION: Hepatic arterial and portal venous flows can be evaluated quantitatively to some extent with appropriate outflow velocity constant limits using the CMA of IV-CT.

Quantitative estimation of progression of chronic liver disease using gadoxetate disodium-enhanced magnetic resonance imaging.

AIM: The purpose of this study was to determine whether the liver stiffness (LS) measured on magnetic resonance (MR) elastography can be estimated by a combination of gadoxetate disodium-enhanced MR imaging (EOB-MRI) and ordinary blood tests. METHODS: We evaluated 33 consecutive patients with suspected liver disease who underwent EOB-MRI using a Differential Subsampling with Cartesian Ordering MR sequence and MR elastography using a 1.5-T MR system in this prospective study. A stepwise multiple linear regression model analysis of LS was performed using various predictive values obtained from two-in-one-uptake, two-compartment model analysis of EOB-MRI (velocity constants of arterial inflow [K1a ], portal venous inflow [K1p ], hepatocellular uptake [Ki ]), and ordinary blood test results (blood platelet count, serum albumin level [ALB], total serum bilirubin level [T-BIL], and prothrombin time [PT%]). RESULTS: Multiple linear regression model analysis revealed that hepatic perfusion-uptake index (HPUI = -K1a + K1p + Ki ) (P < 0.0001), albumin-bilirubin linear predictor (ALBI-LP = 0.66 × log10 T-BIL - 0.085 × ALB) (P = 0.034), and blood platelet count (P = 0.046) were significant independent predictors of LS (r = 0.863). The area under receiver operator characteristics curve of multiple linear regression model in prediction of the liver stiffness corresponding to higher (LS > 5.0 kPa) and lower (LS < 4.2 kPa) risk for developing hepatocellular carcinoma were 0.956 and 0.938, respectively. CONCLUSION: LS can be estimated quantitatively with the use of HPUI obtained from compartment model analysis of EOB-MRI combined with ALBI-LP and blood platelet count.

Evaluation of splenic perfusion and spleen size using dynamic computed tomography: Usefulness in assessing degree of liver fibrosis.

AIM: To enhance the usefulness of splenic perfusion evaluated by means of dynamic computed tomography (CT) and spleen size in assessing the degree of liver fibrosis. METHODS: We retrospectively studied 133 patients who had undergone dynamic CT before hepatectomy. Fibrosis was histologically established in all. First we calculated splenic perfusion parameters K1 (inflow rate constant), 1/k2 (mean transit time; MTT), and K1 /k2 (distribution volume; Vd ), using compartment model analysis. Then we compared the stage of fibrosis with splenic perfusion and spleen size (long axis, R), using the Kruskal-Wallis test and multiple comparisons. After that, we assessed the diagnostic accuracy of the combination of splenic perfusion, spleen size, age, gender, and the presence or absence of hepatitis B and hepatitis C viral infection in detecting liver fibrosis, using stepwise regression and receiver operating characteristic analysis. RESULTS: Significant differences (P < 0.05) in MTT were observed in comparisons between fibrosis stages F0 and F4, between F1 and F4, and between F2 and F4. Significant differences (P < 0.05) in R were observed in comparisons between F0 and F4, and between F1 and F4. Considering the presence or absence of hepatitis B and C viral infection along with MTT and R, the areas under the receiver operating characteristic curves were 0.89 for ≥F1, 0.83 for ≥F2, 0.82 for ≥F3, and 0.82 for F4. CONCLUSION: Splenic MTT and spleen size are helpful in assessing liver fibrosis.

Uterine cervical adenocarcinoma associated with lobular endocervical glandular hyperplasia: Radiologic-pathologic correlation.

AIM: We aimed to identify the radiologic features of uterine cervical adenocarcinoma associated with lobular endocervical glandular hyperplasia (LEGH). METHODS: We retrospectively analyzed magnetic resonance (MR) images and pathologic findings of eight patients who underwent preoperative MR imaging followed by surgical resection and who were pathologically diagnosed with adenocarcinoma (except for adenocarcinoma in situ) associated with LEGH. We assessed the following MR findings: multicystic component (MC), solid component (SC), signal intensity of SC on diffusion-weighted imaging (DWI) and the apparent diffusion coefficient (ADC) map, and radiological stage (r-stage) based on the FIGO classification. A pathologist reevaluated the pathological stage (p-stage) according to the FIGO classification. We correlated the MR findings with the pathologic features. RESULTS: Eight patients were classified into the following three types based on the MR findings: type A, MC and SC; type B, only SC; and type C, only MC. In the five patients with type A, diffusion restriction (DR) was seen on DWI and the ADC map. In 80% of type A cases, the r-stage matched the p-stage. In the one patient with type B, DR was not seen on DWI or the ADC map, and the r-stage matched the p-stage. In the remaining type C cases, DR was not seen on DWI or the ADC map, and the r-stage was underestimated compared with the p-stage. CONCLUSION: On MR imaging, the most common type of adenocarcinoma with LEGH is type A; type C is difficult to diagnose as carcinoma.

Usefulness of three-dimensional magnetic resonance cholangiopancreatography with partial maximum intensity projection for diagnosing autoimmune pancreatitis.

PURPOSE: To compare three-dimensional magnetic resonance cholangiopancreatography (MRCP) with/without partial maximum intensity projection (MIP) and endoscopic retrograde cholangiopancreatography (ERCP) in patients with autoimmune pancreatitis (AIP). MATERIALS AND METHODS: Three-dimensional MRCP and ERCP images were retrospectively analyzed in 24 patients with AIP. We evaluated the narrowing length of the main pancreatic duct (NR-MPD), multiple skipped MPD narrowing (SK-MPD), and side branches arising from the narrowed portion of the MPD (SB-MPD) using four MRCP datasets: 5 original images (MIP5), 10 original images (MIP10), all original images (full-MIP), and a combination of these three datasets (a-MIP). The images were scored using a 3- or 5-point scale. The scores of the four MRCP datasets were statistically analyzed, and the positive rate of each finding was compared between MRCP and ERCP. RESULTS: The median scores for SB-MPD on MIP5 and a-MIP were significantly higher than those on MIP10 and full-MIP. In other words, partial MIP is superior to full-MIP for visualization of detailed structures. The positive rate for SB-MPD on full-MIP was significantly lower than that on ERCP, whereas the positive rate on MIP5, MIP10, and a-MIP was not significantly different from that on ERCP. Moreover, the positive rate for NR-MPD and SK-MPD on the MRCP images was significantly higher than that on the ERCP images. CONCLUSION: Partial MIP is useful for evaluating the MPD and is comparable with ERCP for diagnosing AIP.

Epithelioid trophoblastic tumor of the uterus: A case report with radiologic-pathologic correlation.

Herein, we report a rare case of an epithelioid trophoblastic tumor of the uterus with radiologic-pathologic correlation in a 56-year-old postmenopausal woman. On T2-weighted magnetic resonance (MR) imaging, the tumor appeared as a hypointense irregular mass compared with the surrounding myometrium of the uterine corpus and encircled the cavity of the lower uterine segment. On dynamic contrast-enhanced MR images, the tumor appeared as a hypovascular mass and an inhomogeneously hyperintense mass in the delayed phase. In addition, non-contrast computed tomography images showed some spotty areas of very high density within the tumor. These radiologic findings were well correlated with the histological features, such as abundant hyalinization and calcification within the tumor. Accurate interpretation of MR and computed tomography findings was helpful to differentiate epithelioid trophoblastic tumor from other gestational trophoblastic diseases and uterine carcinomas.

Biochemical and Clinical Predictive Approach and Time Point Analysis of Hepatobiliary Phase Liver Enhancement on Gd-EOB-DTPA-enhanced MR Images: A Multicenter Study.

Purpose To identify biochemical factors associated with liver enhancement over time on gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance (MR) images and predict the optimal time point of the hepatobiliary phase in various clinical settings. Materials and Methods This study was approved by the institutional review boards, and written informed consent was obtained from the 1903 patients enrolled. Simple and multiple logistic regression analyses were performed to investigate the biochemical factors associated with liver-to-spleen contrast (LSC) of at least 1.5 in the hepatobiliary phase. Changes in LSC and lesion-to-liver contrast (LLC) of lesions over time (at 5, 10, 15, and 20 minutes) were investigated with a linear mixed-effects model in patients and lesions. For LSC, the optimal cutoff value was determined with receiver operating characteristic analysis of the most significant variable. Differences in LSC and LLC were analyzed in various clinical settings. Results Ultimately, 1870 patients were evaluated, as 33 were excluded according to study criteria. Prothrombin (PT) activity, total bilirubin level (P = .020), and total cholesterol level (P = .005) were significantly associated with LSC of at least 1.5 at 20 minutes, and PT activity was identified as the most significant factor (odds ratio, 1.271; 95% confidence interval: 1.109, 1.455; P = .001). LSC of at least 1.5 at 20 minutes with PT activity of at least 86.9% and less than 86.9% occurred in 555 of 626 patients (88.6%) and 388 of 575 patients (67.5%), respectively. Satisfactory liver enhancement at 20 minutes was significantly more likely to be achieved by patients with hepatitis B virus than by those with hepatitis C virus (P < .001) and by patients with metastasis than by those with hepatocellular carcinoma (P < .001). No significant difference in LLC was observed in patients examined at 1.5 and 3.0 T (P = .133). Conclusion Hepatic enhancement is significantly associated with PT activity, total bilirubin level, and total cholesterol level. PT activity of at least 86.9% could be used to shorten examination times at Gd-EOB-DTPA-enhanced MR imaging. © RSNA, 2016 Online supplemental material is available for this article.

Contrast-enhancement ratio on multiphase enhanced computed tomography predicts recurrence of pancreatic neuroendocrine tumor after curative resection.

BACKGROUND/OBJECTIVE: No previous study has quantitatively investigated the degree of enhancement of pancreatic neuroendocrine tumors (pNETs) using a routine preoperative modality. The aim of this study was to evaluate the contrast-enhancement ratio (CER) of pNETs using multiphase enhanced CT and to assess the impact of the CER on disease recurrence after surgery. METHODS: A retrospective study was performed using data from 47 consecutive patients with pNETs who had undergone curative surgery. The CER of the tumor was calculated by dividing the CT attenuation value obtained during the maximum-enhanced phase by that obtained during the pre-enhanced phase. A region of interest was placed in the largest tumor dimension plane so as to cover as much surface of the tumor as possible while avoiding adjacent normal structures, calcification, and necrotic areas of the tumor. RESULTS: During a median follow-up period of 51 months (range, 1-132 months), a total of 4 patients (8.5%) developed disease recurrence. The median CER value was significantly lower for the patients with recurrence than for the patients without recurrence (2.9 vs. 4.3, P = 0.013). Univariate analyses showed that a CER ≤3.2 was significantly associated with disease recurrence (P < 0.001). All the patients with disease recurrence had tumors that were both large (>20 mm) and weakly enhanced (CER ≤ 3.2), whereas no recurrences were observed even in patients with tumors >20 mm when the CER was greater than 3.2. CONCLUSIONS: CER might be a useful predictor of disease recurrence in patients with pNETs.

Advantages of radial volumetric breath-hold examination (VIBE) with k-space weighted image contrast reconstruction (KWIC) over Cartesian VIBE in liver imaging of volunteers simulating inadequate or no breath-holding ability.

OBJECTIVES: To investigate the superiority of radial volumetric breath-hold examination (r-VIBE) with k-space weighted image contrast reconstruction (KWIC) over Cartesian VIBE (c-VIBE) for reducing motion artefacts. METHODS: We acquired r-VIBE-KWIC and c-VIBE images in 10 healthy volunteers. Each acquisition lasted 24 seconds. The volunteers held their breath for decreasing lengths of time during the acquisitions, from 24 to 0 seconds (protocols A-E). Magnetic resonance images at the level of the right portal vein and confluence of hepatic veins were assessed by two readers using a five-point scale with a higher number indicating a better study. RESULTS: The mean scores for the complete r-VIBE-KWIC series (r-VIBEfull) and first r-VIBE-KWIC series (r-VIBE1) were not significantly lower than those for c-VIBE in any protocols. The mean scores for c-VIBE were lower than those for r-VIBEfull and r-VIBE1 in protocols C and D. The mean score for c-VIBE was lower than that for r-VIBEfull in protocol E. The mean score for the eighth r-VIBE-KWIC series (r-VIBE8) was lower than that for c-VIBE only in protocol B. CONCLUSION: r-VIBE-KWIC minimised artefacts relative to c-VIBE at any slice location. The r-VIBE-KWIC's sub-frame images during the breath-holding period were hardly affected by another failed breath-holding period. KEY POINTS: • A two-reader study revealed r-VIBE-KWIC's advantages over c-VIBE • The image quality of r-VIBE-KWIC's sub-frame images was maintained during breath holding • Full-frame r-VIBE-KWIC images minimized motion artefacts caused by breathing • A complete breath holding over half the acquisition time is recommended for c-VIBE • c-VIBE was susceptible to respiratory motion especially in the subphrenic region.

Usefulness of a management protocol for patients with cervical multicystic lesions: A retrospective analysis of 94 cases and the significance of GNAS mutation.

AIM: The proper preoperative diagnosis and management of cervical proliferative disorders presenting with multiple cysts, including minimal deviation adenocarcinoma (MDA), lobular endocervical glandular hyperplasia (LEGH), and nabothian cyst (NC), have not been fully established. We previously proposed a management protocol comprising a diagnostic approach using cytology, magnetic resonance imaging, and gastric-type mucin and subsequent treatment. We herein evaluate the usefulness of this protocol and implications of GNAS mutations in LEGH. METHODS: The clinical courses of 94 patients with cervical multicystic lesions who visited our hospital between June 1995 and September 2014 were retrospectively analyzed. GNAS mutations were investigated in 10 LEGH, five LEGH with atypia, and two MDA cases. RESULTS: Of the 94 patients, the conditions of 10, 59, and 25 were clinically diagnosed as suspicious of MDA or carcinoma (S/O MDA-Ca), suspicious of LEGH (S/O LEGH), and NC, respectively. Ten patients each with S/O MDA-Ca and S/O LEGH underwent hysterectomy, and the correct ratio for diagnosis was 90% (18/20). Of the 42 S/O LEGH cases followed-up for more than 12 months, three showed an increase in tumor size. After hysterectomy, two were LEGH with atypia while one was NC. The GNAS mutation was detected in two cases of LEGH with atypia, one of which showed an increase in tumor size during follow-up. CONCLUSION: The management protocol we propose herein will be useful. An increase in tumor size is important to detect potentially malignant LEGH. GNAS mutations may be involved in the tumorigenesis of potentially malignant LEGH.