Effect of iodized oil embolization on temperature change during cryoablation for renal cell carcinoma.

INTRODUCTION: We aimed to evaluate the effect of transcatheter arterial embolization (TAE) with iodized oil (Lipiodol) on temperature change during cryoablation (CA) for renal cell carcinoma (RCC). MATERIAL AND METHODS: We retrospectively reviewed patients receiving CA for RCC from February 2020 to July 2021, including those who received Lipiodol TAE prior to CA (TAE group) and those who underwent only CA with comparable clinical and tumor characteristics (non-TAE group). Clinical data and tumor characteristics of both groups were recorded. The temperature readings of each cryoprobe at every 15 s and 'time to -100 °C' were compared between the groups. RESULTS: A total of 17 patients with 18 RCCs were recruited (seven in the TAE group and 11 in the non-TAE group). The 'time to -100 °C' was significantly longer in the TAE group than in the non-TAE group (64.5 ± 24.3 s vs. 48.8 ± 9.7 s, p = 0.018). Positive correlation between 'time to -100 °C' and tumor maximal diameter, RENAL nephrometry and PADUA score were observed in the non-TAE group, while no corresponding correlation was found in the TAE group. CONCLUSIONS: Pre-embolization with iodized oil influences the temporal temperature changes during cryoablation by disrupting the positive correlation between the time to reach the target temperature and tumor characteristics.

Minimal invasive treatment for post-liver and renal transplant lymphatic leaks.

INTRODUCTION: Persistent lymphatic leakage from the surgical drain is a troubling complication occasionally encountered postoperatively. This study investigated lymphatic leaks after renal or liver transplantation, comparing the treatment efficacy of traditional catheter drainage vs. minimally invasive lymphatic interventions. We also discuss access and treatment targets considering the physiology of lymphatic flow. METHODS: Between September 2018 and September 2020, 13 patients with lymphatic leakage were treated with minimally invasive lymphatic interventions; 11 had received a renal transplant, and two received a liver transplant. The control group included 10 patients with postrenal transplant lymphatic leakage treated with catheter drainage. The treatment efficacy of catheter drainage, lymphatic interventions, and different targets of embolization were compared. RESULTS: The technical success rate for lymphatic intervention was 100%, and the clinical success rate was 92%, with an 82.9% reduction in drain volume on the first day after treatment. The duration to reach clinical success was 5.9 days with lymphatic intervention, and 33.9 days with conservative catheter drainage. CONCLUSION: Lymphangiography and embolization are minimally invasive and efficient procedures for treating persistent lymphatic leaks after renal or liver transplantation. We suggest prompt diagnosis and embolization at upstream lymphatics to reduce the duration of drain retention, days of hospitalization, and associated comorbidities.

Autosegmentation of Prostate Zones and Cancer Regions from Biparametric Magnetic Resonance Images by Using Deep-Learning-Based Neural Networks.

The accuracy in diagnosing prostate cancer (PCa) has increased with the development of multiparametric magnetic resonance imaging (mpMRI). Biparametric magnetic resonance imaging (bpMRI) was found to have a diagnostic accuracy comparable to mpMRI in detecting PCa. However, prostate MRI assessment relies on human experts and specialized training with considerable inter-reader variability. Deep learning may be a more robust approach for prostate MRI assessment. Here we present a method for autosegmenting the prostate zone and cancer region by using SegNet, a deep convolution neural network (DCNN) model. We used PROSTATEx dataset to train the model and combined different sequences into three channels of a single image. For each subject, all slices that contained the transition zone (TZ), peripheral zone (PZ), and PCa region were selected. The datasets were produced using different combinations of images, including T2-weighted (T2W) images, diffusion-weighted images (DWI) and apparent diffusion coefficient (ADC) images. Among these groups, the T2W + DWI + ADC images exhibited the best performance with a dice similarity coefficient of 90.45% for the TZ, 70.04% for the PZ, and 52.73% for the PCa region. Image sequence analysis with a DCNN model has the potential to assist PCa diagnosis.

High Signal in Bone Marrow on Diffusion-Weighted Imaging of Female Pelvis: Correlation With Anemia and Fibroid-Associated Symptoms.

BACKGROUND: The diffusion-weighted imaging (DWI) signals of the female pelvic bone marrow show great variability and are usually high in female patients with fibroid-associated symptoms and anemia. PURPOSE: To ascertain clinical factors contributing to high signal intensity in the bone marrow of the female pelvis on DWI. STUDY TYPE: Retrospective case-control study. SUBJECTS: A single-institution review of 221 female patients underwent a pelvic magnetic resonance study from December 2012 to July 2014. FIELD STRENGTH/SEQUENCE: 1.5T/DWI (b = 0 and 1000) and apparent diffusion coefficient (ADC). ASSESSMENT: The ADC of pelvic bone marrow and the muscle-normalized signal intensity (SI) on DWI (mnDWI) were measured. A brightness grading scale ranging from 0 to 4 was used for pelvic bone assessment. Clinical factors, namely, age, the lowest hemoglobin level in the last 6 months, the presence of large uterine fibroids, and/or adenomyosis and fibroid-associated symptoms were recorded. STATISTICAL TESTS: The relationships between the brightness grade and clinical factors were evaluated through multinomial logistic regression, and correlations of mnDWI and the ADC with the clinical factors were analyzed through the Kruskal-Wallis test, Jonckheere's trend test, and the Mann-Whitney U-test with Bonferroni correction. RESULTS: Age and the hemoglobin level were inversely associated with the bone marrow brightness grade on DWI (both P < 0.05), whereas the presence of fibroid-associated symptoms showed a positive association (P = 0.028). The ADC and mnDWI in women younger than 50 years were significantly higher than those in older women (both P < 0.0001). The ADC had no significant correlation with anemia (P = 0.511), whereas mnDWI increased as the severity of anemia increased (P = 0.00154). DATA CONCLUSION: Our study showed an association of high DWI SI of pelvic bone marrow with anemia in premenopausal women. LEVEL OF EVIDENCE: 4 Technical Efficacy Stage 3 J. Magn. Reson. Imaging 2018;48:1024-1033.

Prognostic factors of primary resected retroperitoneal soft tissue sarcoma: Analysis from a single asian tertiary center and external validation of gronchi's nomogram.

BACKGROUND: Surgery is the potentially curative treatment for retroperitoneal sarcoma (RS), but complete resectability is frequently a challenge. This study aimed to characterize the clinical features, prognostic factors and treatment outcomes. METHODS: A cohort of 144 patients with RS was surveyed retrospectively from January 1st, 2000 to July 30th, 2011. The prognostic influence of clinicopathological characteristics as well as treatments on local recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), and overall survival (OS), were examined by univariate and multivariate analyses. A histology-specific nomogram developed by Gronchi et al was used for validation. RESULTS: Liposarcoma, leiomyosarcoma, and malignant peripheral sheath tumor (MPNST) were the most common histologies (70%). Multivariate analysis revealed FNCLCC tumor grade was the most significant prognostic factor for OS (P = 0.001) and DMFS (P < 0.001) and complete resection was the only significant prognostic factor for LRFS (P = 0.043). Incomplete resection of grade 3 tumor was significantly associated with a worse OS. Despite some differences in characteristics between our patients and Gronchi's cohort, external validation of Gronchi's nomogram demonstrated excellent concordance in predicting survival. CONCLUSIONS: Our study demonstrated tumor grade and surgical margins had significant prognostic influence and the Gronchi's nomogram has an excellent applicability in predicting survival of STS patients. J. Surg. Oncol. 2016;113:355-360. © 2016 Wiley Periodicals, Inc.

Epidermoid cyst of the testis: An atypical sonographic appearance.

Epidermoid cysts are rare. They represent the most common benign tumor of the testis. The sonographic appearances of testicular epidermoid cysts usually include avascular, mostly lamellated, heterogeneous internal echotexture, with hypoechoic and hyperechoic concentric rings, accounting for the typical onion-ring appearance. On MRI, epidermoid cysts show a low-signal-intensity center, with internal concentric rings of alternating high- and low-signal intensity on T2-weighted images, which correlates with the onion-ring appearance. We report a patient with testicular epidermoid cyst with atypical ultrasound and MRI appearances that led to the erroneous initial diagnosis of "burned-out" tumor. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:448-451, 2016.

Percutaneous cryoablation for inoperable malignant lung tumors: midterm results.

OBJECTIVE: To retrospectively analyze the efficacy and short- to mid-term survival rate of cryoablation for malignant lung tumors. METHODS: Percutaneous CT-guided cryoablation for 45 malignant lung tumors in 26 patients during 41 sessions from 2009 to 2013 were performed. Follow up CT-scan were used to determine local tumor progression. Survival rate, local tumor control rate and associated risk factors were analyzed. RESULTS: The immediate during and short-term complications with CTCAE grade 2 or upper include pneumothorax (15%), pleural effusion (20%), pulmonary hemorrhage (24%), pneumonitis (15%), hemothorax (15%), hemoptysis (10%), pain (20%), bronchopleural fistula (n=1), and empyema (n=2). Life-threatening bleeding or hemodynamic instability was not observed. There was no procedural-related mortality. Overall survival rate of 1, 2, 3 years are 96%, 88%, 88%. For curative intent, local tumor control (LTC) rate of 1, 2, 3 years are 75%, 72%, 72%. CONCLUSION: Cryoablation for malignant lung tumors is effective and feasible in local control of tumor growth, with good short- to mid-term survival rate, as an alternative option for inoperable patients.

Evaluation of the extent of ketamine-induced uropathy: the role of CT urography.

BACKGROUND: With growing ketamine abuse, ketamine-induced uropathy (KIU) has become more prevalent in recent years. This research evaluates the presence, distribution and extent of KIU in the upper and lower urinary tracts by retrospectively reviewing CT urography (CTU) images. METHODS: Patients diagnosed with KIU who underwent CT scanning from 1 January 2006 to 31 December 2011 were recruited. The CT protocols included three-phase CTU in six patients, split-bolus CTU in 17, two-phase CT in one and unenhanced CT in three. The CT images were retrospectively reviewed by two radiologists. RESULTS: A total of 27 patients participated in this study. The common CT findings included diffuse bladder wall thickening (88.9%), small bladder volume (66.7%) and perivesical inflammation (44.4%). Twelve patients (44.4%) were diagnosed with hydronephrosis, including three patients with unilateral hydronephrosis and nine with bilateral hydronephrosis. Of these patients, nine had ureteral wall thickening (33.3%) and two (7.4%) had ureterovesical junction involvement (ie, they had hydronephrosis but no ureteral wall thickening). One patient had a ureteral obstruction because of a ureter stone. The correlation between upper urinary tract involvement and grading of the interstitial cystitis was statistically non-significant (p=0.33). Four patients (14.8%) had a vesicovaginal fistula which could be detected in the excretory phase only. CONCLUSIONS: Upper urinary tract involvement is common in patients with KIU. CTU might aid evaluation of the extent of KIU and prompt adequate management.

Retroperitoneal dedifferentiated liposarcoma with rare heterologous low-grade osteosarcoma: A case report.

Dedifferentiated liposarcoma is a high-grade entity developed from a preexisting or recurrent well-differentiated liposarcoma, and rarely, it may contain divergent differentiation. We presented the case of a 39-year-old woman with retroperitoneal dedifferentiated liposarcoma with heterologous low-grade osteosarcoma, possessing a special pattern of tumoral calcification.

Feasibility estimation of injected hydrodissection before definitive radiotherapy of pancreatic adenocarcinoma.

BACKGROUND: Pancreatic adenocarcinoma is often not diagnosed until an advanced stage, and so most patients are not eligible for resection. For patients who are inoperable, definitive radiotherapy is crucial for local disease control. However, the pancreas is located close to other vulnerable gastrointestinal organs, making it challenging to deliver an adequate radiation dose. The surgical insertion of spacers or injection of fluids such as hydrogel before radiotherapy has been proposed, however, no study has discussed which patients are suitable for the procedure. METHODS: In this study, we reviewed 50 consecutive patients who received definitive radiotherapy at our institute to determine how many could have benefitted from hydrodissection to separate the pancreatic tumor from the adjacent gastrointestinal tract. By hypothetically injecting a substance using either computed tomography (CT)-guided or endoscopic methods, we aimed to increase the distance between the pancreatic tumor and surrounding hollow organs, as this would reduce the radiation dose delivered to the organs at risk. RESULTS: An interventional radiologist considered that hydrodissection was feasible in 23 (46%) patients with a CT-guided injection, while a gastroenterologist considered that hydrodissection was feasible in 31 (62%) patients with an endoscopic injection. Overall, we found 14 (28%) discrepancies among the 50 patients reviewed. Except for 1 patient who had no available trajectory with a CT-guided approach but in whom hydrodissection was considered feasible with an endoscopic injection, the other 13 patients had different interpretations of whether direct invasion was present in the CT images. CONCLUSION: Our results suggested that about half of the patients could have benefited from hydrodissection before radiotherapy. This finding could allow for a higher radiation dose and potentially better disease control.

Are there useful CT features to differentiate renal cell carcinoma from lipid-poor renal angiomyolipoma?

OBJECTIVE: This study was an attempt to identify key CT features that can potentially be used to differentiate between lipid-poor renal angiomyolipoma and renal cell carcinoma (RCC). MATERIALS AND METHODS: We conducted an analysis of patients who received nephrectomy or renal biopsy from 2002 to 2011 with suspected RCC. We included tumors smaller than 7 cm with a completed three-phase CT examination. A radiologist and a urology fellow, blinded to histopathologic diagnosis, recorded the imaging findings by consensus and compared the values for each parameter between lipid-poor angiomyolipoma, RCC subtypes, and RCC as a group. Multivariate logistic regression analysis was performed for each univariate significant feature. RESULTS: The sample in our study consisted of 132 patients with 135 renal tumors, including 51 men (age range, 26-84 years; mean age, 57 years) and 81 women (age range, 29-91 years; mean age, 57 years). These tumors included 33 lipid-poor angiomyolipomas, 54 clear-cell RCC, 31 chromophobe RCC, and 17 papillary RCC. Multivariate analysis revealed four significant parameters for differentiating RCC as a group from lipid-poor angiomyolipoma (angular interface, p = 0.023; hypodense rim, p = 0.045; homogeneity, p = 0.005; unenhanced attenuation > 38.5 HU, p < 0.001), five for clear-cell RCC, two for chromophobe RCC, and one for papillary RCC. Lipid-poor angiomyolipoma and clear-cell RCC showed early strong enhancement and a washout pattern, whereas chromophobe RCC and papillary RCC showed gradual enhancement over time. CONCLUSION: Specific CT features can potentially be used to differentiate lipid-poor renal angiomyolipoma from renal cell carcinoma.

Percutaneous radiofrequency ablation of renal cell carcinomas in patients with von Hippel Lindau disease: indications, techniques, complications, and outcomes.

Renal cell carcinoma (RCC) in patients with von Hippel Lindau (VHL) disease tends to be multifocal, bilateral, and recur or develop new tumors after removal. These characteristics make treating hereditary RCCs difficult for urologists or radiologists compared to treating a sporadic RCC. Radiofrequency ablation (RFA) is a minimally-invasive treatment for small hereditary RCCs associated with a low complication rate and a minimal decrease in renal function. No RFA guidelines have been established about what to treat and when and how to ablate RCCs in patients with VHL disease. Besides, reports on complications and treatment outcomes in this patient group are rare. The purpose of this review is to discuss the indications, techniques, complications, and outcomes of RFA in treating RCC in patients with VHL disease.

Combining prostate health index and multiparametric magnetic resonance imaging may better predict extraprostatic extension after radical prostatectomy.

BACKGROUND: In patients undergoing radical prostatectomy (RP) for prostate cancer (PCa), preoperative prediction of extraprostatic extension (EPE) can facilitate patient selection for nerve-sparing procedures. Since both multiparametric magnetic resonance imaging (mpMRI) and prostate health index (PHI) have shown promise for the diagnosis and prognostication of PCa, we investigated whether a combination of mpMRI and PHI evaluations can improve the prediction of EPE after RP. METHODS: Patients diagnosed with PCa and treated with RP were prospectively enrolled between February 2017 and July 2019. Preoperative blood samples were analyzed for PHI (defined as [p2PSA/fPSA] × âˆštPSA), and mpMRI examinations were performed and interpreted by a single experienced uroradiologist retrospectively. The area under the receiver operating characteristic curve (ROC) was used to determine the performance of mpMRI, PHI, and their combination in predicting EPE after RP. RESULTS: A total of 163 patients were included for analysis. The pathological T stage was T3a or more in 59.5%. Overall staging accuracy of mpMRI for EPE was 72.4% (sensitivity and specificity: 73.2% and 71.2%, respectively). The area under the ROC of the combination of mpMRI and PHI in predicting EPE (0.785) was higher than those of mpMRI alone (0.717; p = 0.0007) and PHI alone (0.722; p = 0.0236). mpMRI showed false-negative non-EPE results in 26 patients (16%), and a PHI threshold of >40 could avoid undiagnosed EPE before RP in 21 of these 26 patients. CONCLUSION: The combination of PHI and mpMRI may better predict the EPE preoperatively, facilitating preoperative counseling and tailoring the need for nerve-sparing RP.

Management of Patients with Adhesive Capsulitis via Ultrasound-Guided Hydrodilatation without Concomitant Intra-Articular Lidocaine Infusion: A Single-Center Experience.

Considering the potential chondrotoxic effects of lidocaine, this retrospective study aimed to examine whether ultrasound-guided hydrodilatation without concurrent lidocaine infusion can still provide comparable treatment benefits for patients with adhesive capsulitis (AC). Outpatient data from 104 eligible AC patients who received ultrasound-guided hydrodilatation between May 2016 and April 2021 were reviewed. A total of 59 patients received hydrodilatation with diluted corticosteroid only, while 45 patients received treatment with mixed, diluted corticosteroid and 1% lidocaine. The overall treatment outcome was documented as the percentage of clinical improvement, ranging from 0% to 100% compared to baseline, and it was ranked into poor, moderate and good treatment outcomes. The results show no significant group-wise difference in demographics, overall treatment outcome, and number of hydrodilatations, while most patients showed moderate and good treatment outcomes. Patients with lidocaine infusion did not show greater treatment benefit. Our results suggest that ultrasound-guided hydrodilatation without concurrent lidocaine infusion can still deliver good treatment benefits for AC patients, and the findings are supportive of a modified approach toward careful intra-articular local anesthetic use during management of AC in the primary care setting.

A theoretical analysis of prophylactic common iliac arterial occlusion for potential massive bleeding during cesarean delivery: Decision-making considerations - A 2-year retrospective study.

OBJECTIVE: According to the American College of Obstetricians and Gynecologists, there has been a rapid increase in the total cesarean birth rates. The rate of placenta accreta is increasing, and previous cesarean delivery is the most common risk factor. Labor is a major challenge in cases with an abnormally invasive placenta, considering the risk of massive blood loss during cesarean delivery and patient wishes for uterine preservation. MATERIALS AND METHODS: We retrospectively obtained clinical data and surgical outcomes of high-risk cases of placenta previa totalis and placenta accreta admitted between March 2018 and September 2020. A multidisciplinary discussion was conducted before surgery. We also constructed an organizational flowchart detailing this decision-making process. RESULTS: Patients who underwent cesarean delivery for suspected placenta accreta or placenta previa totalis with clinical risk factors were reviewed. No patient required an emergency hysterectomy or intensive care unit admission. CONCLUSION: We shared our experience of multidisciplinary decision-making by presenting high-risk cases of placenta previa totalis with clinical risk factors or suspected placenta accreta. Based on our multidisciplinary decision-making process, all patients were discharged without complications.

Parallel second stent placement for refractory ureteral stent malfunction in malignant ureteral obstruction.

PURPOSE: To review retrospectively the outcome of placement of a parallel second ureteral stent in patients with urinary obstruction secondary to a malignancy. MATERIALS AND METHODS: During the period 2005-2008, the medical records of patients with ureteral obstruction from an abdominal malignancy were reviewed. Patients who experienced malfunction of the first ureteral stent subsequently underwent either initial stent exchange (control group) or a parallel second ureteral stent placement. The outcomes of both groups were evaluated in terms of stent function at 1 week, 1 month, and 3 months after the procedure. Several clinical and imaging parameters were also compared between the two groups. RESULTS: The stent malfunction rate increased more rapidly in the control group. In 1 week, the malfunction rate was 29.4% in the parallel ureteral stent group and 56.7% in the control group. By the end of the third month, the malfunction rate was 72.7% in the parallel ureteral stent group and 100% in the control group. The creatinine level after the procedure was significantly lower in the parallel ureteral stent group (P = 0.004). The incidence of symptomatic urinary tract infection (UTI) was around 30% in both groups (P = 1.000). CONCLUSIONS: Parallel second ureteral stent placement has a high technical success rate. For terminally ill patients who have a malignancy and an occluded ureteral stent, the technique can effectively relieve obstruction and prolong the function of the stent.

Asian Conference on Tumor Ablation Guidelines for Adrenal Tumor Ablation.

Thermal ablation is a good alternative treatment in patients who are unable to undergo adrenalectomy. Even though the Asian Conference on Tumor Ablation (ACTA) has been held for many years, adrenal ablation guidelines have not been established. No guidelines for adrenal ablation are established in American and European countries, either. The aim of this review was to introduce the first version of ACTA guidelines for adrenal tumor ablation.

Asian Conference on Tumor Ablation guidelines for renal cell carcinoma.

Thermal ablation has been established as an alternative treatment for renal cell carcinoma (RCC) in patients who are poor candidates for surgery. However, while American and European guidelines have been established for American and European patients, respectively, no ablation guidelines for Asian patients with RCCs have been established many years after the Asian Conference on Tumor Ablation (ACTA) had been held. Given that Western guidelines are difficult to apply to Asian patients due to differences in body habitus, economic status, and insurance systems, the current review sought to establish the first version of the ACTA guidelines for treating a RCC with thermal ablation.

Endometriosis-associated epithelial ovarian cancer is a more complicated disease than we suspected before.

OBJECTIVE: Endometriosis-associated epithelial ovarian cancer (EOC) often includes clear cell carcinoma and endometrioid-type carcinoma. Due to the low incidence of primary mucinous EOC and absence of association between endometriosis and primary mucinous EOC, we present an unusual endometriosis-associated mixed mucinous and endometrioid adenocarcinoma arising from the same ovary. CASE REPORT: A 54-year-old woman had an abdominal palpable mass for months. Medical and surgical history, as well as preoperative surveys was unremarkable, except of presence of a pelvic mass. She underwent an exploration laparotomy, and a 22-cm right ovarian tumor was found. Grossly, right ovarian tumor containing brownish cloudy cystic fluid 2450 ml and an apparent 4 × 4 × 2 cm-sized papillary growth. Microscopically, a confluent glandular and infiltrative pattern presented endometrioid adenocarcinoma, and cells with intracytoplasmic mucin and stratified elongated epithelial cells presented mucinous adenocarcinoma. Surgico-pathological stage was FIGO IIIA due to tumor invading to the peritoneum above the pelvis. Postoperatively, the dose-dense chemotherapy was applied with uneventful outcome. CONCLUSION: This is a rare case, composed with mixed mucinous and endometrioid adenocarcinoma of the same ovary, suggesting that careful pathological diagnosis of endometriosis-associated EOC is needed.