Predicting resection margin status of pancreatic neuroendocrine tumors on CT: performance of NCCN resectability criteria.

OBJECTIVE: To test the performance of the National Comprehensive Cancer Network (NCCN) CT resectability criteria for predicting the surgical margin status of pancreatic neuroendocrine tumor (PNET) and to identify factors associated with margin-positive resection. METHODS: Eighty patients with pre-operative CT and upfront surgery were retrospectively enrolled. Two radiologists assessed the CT resectability (resectable [R], borderline resectable [BR], unresectable [UR]) of the PNET according to NCCN criteria. Logistic regression was used to identify factors associated with resection margin status. κ statistics were used to evaluate interreader agreements. Kaplan-Meier method with log-rank test was used to estimate and compare recurrence-free survival (RFS). RESULTS: Forty-five patients (56.2%) received R0 resection and 35 (43.8%) received R1 or R2 resection. R0 resection rates were 63.6-64.2%, 20.0-33.3%, and 0% for R, BR, and UR diseases, respectively (all p ≤ 0.002), with a good interreader agreement (κ, 0.74). Tumor size (<2 cm, 2-4 cm, and >4 cm; odds ratio (OR), 9.042-18.110; all p ≤ 0.007) and NCCN BR/UR diseases (OR, 5.918; p = 0.032) were predictors for R1 or R2 resection. The R0 resection rate was 91.7% for R disease <2 cm and decreased for larger R disease. R0 resection and smaller tumor size in R disease improved RFS. CONCLUSION: NCCN resectability criteria can stratify patients with PNET into distinct groups of R0 resectability. Adding tumor size to R disease substantially improves the prediction of R0 resection, especially for PNETs <2 cm. ADVANCES IN KNOWLEDGE: Tumor size and radiologic resectability independently predicted margin status of PNETs.

Plasma galectin-3 concentration and estimated glomerular filtration rate in patients with type 2 diabetes with and without albuminuria.

This study aimed to investigate the association between galectin-3 concentration and estimated glomerular filtration rate (eGFR) in patients with type 2 diabetes mellitus (T2DM) with and without albuminuria. In this cross-sectional study, we examined 334 patients with T2DM. The eGFR was calculated using a creatinine-based formula (eGFRcrea) and a combined creatinine-cystatin C equation (eGFRcrea-cyst). The participants were categorized into two groups based on the urinary albumin-to-creatinine ratio (UACR): patients without albuminuria (UACR < 30 mg/g) and those with albuminuria (UACR ≥ 30 mg/g). Greater concentrations of plasma galectin-3 were associated with lower eGFRcrea-cyst and eGFRcrea levels in patients with and without albuminuria. Plasma galectin-3 concentrations were negatively correlated with eGFRcrea-cyst in patients with normoalbuminuria and albuminuria (γ = - 0.405, P < 0.001; γ = - 0.525, P < 0.001, respectively). Galectin-3 concentrations were significantly associated with eGFRcrea-cyst after adjusting for sex, age, and other confounding factors, including UACR as a categorical or continuous variable in multiple regression analyses (ß = - 0.294, 95% CI - 70.804 to - 41.768, P < 0.001; ß = - 0.265, 95% CI - 65.192 to - 36.550, P < 0.001, respectively). Likewise, when eGFRcrea-cyst was treated in place of eGFRcrea, this result was replicated in the correlation and regression analyses. Galectin-3 concentration was negatively associated with eGFR in patients with T2DM, independent of albuminuria status.

Radiofrequency ablation using real-time ultrasonography-computed tomography fusion imaging improves treatment outcomes for T1a renal cell carcinoma: Comparison with laparoscopic partial nephrectomy.

PURPOSE: To determine whether real-time ultrasonography-computed tomography (US-CT) fusion imaging can improve technical feasibility versus B-mode US and provide comparable outcomes of radiofrequency ablation (RFA) for T1a renal cell carcinoma (RCC) compared with laparoscopic partial nephrectomy (LPN). MATERIALS AND METHODS: Between June 2013 and August 2016, biopsy- or pathologically confirmed stage T1a RCCs were retrospectively reviewed. Of these, 39 cases were included in the RFA group, and 46 cases were included in the LPN group. In the RFA group, we evaluated tumor visibility and technical feasibility before RFA on a four-point scale on B-mode US and US-CT fusion images. After RFA, hospital days, creatinine value, complications, and disease-free survival rate were compared between the two groups. All results were analyzed by use of the Mann-Whitney U-test and Kaplan-Meier method. RESULTS: Compared with B-mode US alone, real-time US-CT fusion significantly improved the tumor visibility score and overall mean technical feasibility grade (p<0.001). The 5-year disease-free survival rate was 97.4% and 97.8% in the RFA and LPN groups, respectively, and there was no statistically significant difference between groups (p=0.1). Mean periprocedural creatinine levels were significantly lower in the RFA group than in the LPN group. The number of hospital days was shorter in the RFA group. Minor complications were present in 5.1% of the RFA group and 13.0% of the LPN group, with no major complications. CONCLUSIONS: US-CT fusion-image-guided RFA improved tumor visibility scores and overall mean technical validity and resulted in a comparable disease-free survival rate to LPN.

A Real-World Comparative Study of Microwave and Radiofrequency Ablation in Treatment-Naïve and Recurrent Hepatocellular Carcinoma.

The efficacy and safety of microwave ablation (MWA) compared to radiofrequency ablation (RFA) for patients with treatment-naïve and recurrent hepatocellular carcinoma (HCC) has not been clarified in Korea. There were 150 HCC patients (100 in the RFA group and 50 in the MWA group) enrolled in our study. The primary outcome was one- and two-year disease-free survival (DFS). Secondary outcomes were complete response (CR) rate, two-year survival rate, risk factors for DFS and complication rate. Treatment outcomes were also assessed using propensity-score matching (PSM). The MWA group had better one- and two-year DFS than the RFA group (p = 0.035 and p = 0.032, respectively), whereas the CR rate, two-year survival rate, and complication rate were similar between the two groups with fewer major complications in the MWA group (p = 0.043). Patients with perivascular tumors, high risk of recurrence, and small tumor size (≤3 cm) were more suitable for MWA than RFA. MWA was also an independent factor for favorable one- and two-year DFS. Finally, the MWA group still showed better one- and two-year DFS than the RFA group after PSM. In conclusion, MWA could be an alternative treatment to RFA especially in patients with a high risk of recurrence, perivascular tumors, and small tumor size.

Relationship between plasma growth differentiation factor-15 level and estimated glomerular filtration rate in type 2 diabetes patients with and without albuminuria.

AIM: To assess the relationship between growth differentiation factor-15 (GDF-15) levels and estimated glomerular filtration rate (eGFR) in type 2 diabetes mellitus (DM) patients with and without albuminuria. METHODS: We examined 324 patients with type 2 DM in a cross-sectional study. eGFR was determined using equations from creatinine (eGFRcr) and the combination of creatinine and cystatin C (eGFRcr-cys). The patients were classified into two groups based on urinary albumin: creatinine ratio (ACR): the normoalbuminuria group (urinary ACR < 30 mg/g) and the albuminuria group (urinary ACR ≥ 30 mg/g). RESULTS: In individuals both with and without albuminuria, higher GDF-15 levels were associated with lower eGFRcr and eGFRcr-cys. Plasma GDF-15 levels were inversely correlated with eGFRcr in individuals both with and without albuminuria (γ = -0.624, p < 0.001 and γ = -0.509, p < 0.001, respectively). A multiple regression analysis showed that GDF-15 levels were significantly associated with eGFRcr after adjusting for age, sex and other confounders, including urinary ACR as a continuous or categorical variable (ß = -0.309, p < 0.001 and ß = -0.318, p < 0.001, respectively). Similarly, these results were replicated when eGFRcr-cys was considered instead of eGFRcr in correlation and regression analyses. CONCLUSION: GDF-15 levels were inversely associated with eGFR in patients with type 2 DM. This relationship was independent of albuminuria status.

Radiofrequency Ablation of Hepatocellular Carcinoma (≤ 5 cm) with Saline-Perfused Electrodes: Factors Affecting Local Tumor Progression.

Purpose: We aimed to assess local tumor progression (LTP) rate and associated prognostic factors in 92 patients who underwent radiofrequency ablation (RFA) using saline-perfused electrodes to treat hepatocellular carcinoma (HCC) (≤ 5 cm). Materials and Methods: Total 92 patients with 148 HCCs were treated with RFA using salineperfused electrodes, from 2009 to 2015. We retrospectively evaluated technical success, technique efficacy, and LTP rates. Potential prognostic factors for LTP were perivascular tumor, subphrenic tumor, artificial ascites, tumor size (≥ 2 cm), and previous treatment of transarterial chemoembolization. Analysis was performed by lesion, rather than by person. Results: During follow-up period from 1 to 97.4 months, total cumulative LTP rates were 7.9%, 11.4%, and 14.6% at 1, 3, and 5 years, respectively. These values were significantly higher in the perivascular (35.1%; p = 0.009) and subphrenic group (38.9%; p = 0.002) at 5-year. We did not observe any significant difference in LTP according to other prognostic factors (p > 0.05). Conclusion: RFA with saline-perfused electrode is a safe and effective treatment modality for HCC (≤ 5 cm), with lower LTP rates. Nevertheless, perivascular and subphrenic HCCs demonstrated higher LTP rate than other sites. It is imperative to note that perivascular and subphrenic location of HCC are associated with a high risk of local recurrence, despite the use of salineperfused electrodes.

Association Between Gastric Emptying Time and Incidence of Cardiovascular Diseases in Subjects With Diabetes.

BACKGROUND/AIMS: Delayed gastric emptying (GE) is associated with high morbidity and mortality in subjects with diabetes. The aim of this study is to investigate associations between GE time and the major cardiovascular events (coronary heart diseases and ischemic stroke) in diabetic subjects with upper gastrointestinal (UGI) symptoms. METHODS: Among 259 subjects with chronic UGI symptoms who underwent gastric emptying study (GES) over 13 years, 122 diabetic subjects without gastric surgery and/or rapid GE were enrolled in this study. We also gathered data about baseline demographics, clinical characteristics, estimated GE half-time (GE T½) and incidence of cardiovascular events following GES. RESULTS: The mean age of subjects was 64.0 ± 17.4 years. There were 86 women and 104 subjects with type 2 diabetes. There were 52 (42.6%) subjects with normal GE, 50 (41.0.%) subjects with mild delayed GE, and 20 (16.4%) subjects with marked delayed GE. During follow-up (median, 207 weeks), cardiovascular events occurred in 7 (13.5%) subjects with normal GE, 4 (8.0%) subjects with mild delayed GE and 7 (35.0%) subjects with marked GE ( P = 0.015). Univariate analysis showed that GE T½ was significantly associated with incidence of cardiovascular events (crude OR, 1.74; 95% CI, 1.12-2.69; P = 0.014). In a multivariate model, association between GE T½ and incidence of cardiovascular events remained statistically significant after adjustment for baseline characteristics and comorbidities (adjusted OR, 1.94; 95% CI, 1.21-3.12; P = 0.006). CONCLUSION: A delay of GE was associated with an increased incidence of cardiovascular events in diabetic subjects with chronic UGI symptoms.

Assessment of patient-reported outcomes (PROs): treatment satisfaction, medication adherence, and quality of life (QoL) and the associated factors in postmenopausal osteoporosis (PMO) patients in Korea.

Patient-reported outcomes (PROs) provide practical guides for treatment; however, studies that have evaluated PROs of women in Korea with postmenopausal osteoporosis (PMO) are lacking. This cross-sectional, multi-center (29 nationwide hospitals) study, performed from March 2013 to July 2014, aimed to assess PROs related to treatment satisfaction, medication adherence, and quality of life (QoL) in Korean PMO women using osteoporosis medication for prevention/treatment. Patient demographics, clinical characteristics, treatment patterns, PROs, and experience using medication were collected. The 14-item Treatment Satisfaction Questionnaire for Medication (TSQM) (score-range, 0-100; domains: effectiveness, side effects, convenience, global satisfaction), Osteoporosis-Specific Morisky Medication Adherence Scale (OS-MMAS) (score-range, 0-8), and EuroQol-5 dimensions questionnaire (index score range, - 0.22 to 1.0; EuroQol visual analog scale score range, 0-100) were used. To investigate factors associated with PROs, linear (treatment satisfaction/QoL) or logistic (medication adherence) regression analyses were conducted. A total of 1804 patients (age, 62 years) were investigated; 60.1% used bisphosphonate, with the majority (67.2%) using weekly medication, 27.8% used daily hormone replacement therapy, and 12.1% used daily selective estrogen receptor modulator. Several patients reported gastrointestinal (GI) events (31.6%) and dental visits due to problems (24.1%) while using medication. Factors associated with the highest OS-MMAS domain scores were convenience and global satisfaction. GI events were associated with non-adherence. TSQM scores for effectiveness, side effects, and GI risk factors were significantly associated with QoL. Our study elaborately assessed the factors associated with PROs of Korean PMO women. Based on our findings, appropriate treatment-related adjustments such as frequency/choice of medications and GI risk management may improve PROs.

Clinical Characteristics, Causes and Survival in 115 Cancer Patients with Parathyroid Hormone Related Protein-mediated Hypercalcemia.

BACKGROUND: The aim of this study is to determine the proportion of cancers presenting with parathyroid hormone (PTH) related protein (PTHrP)-mediated hypercalcemia, examine the clinical and biochemical characteristics, identify predictive factors for survival. And we also compared those characteristics between solid organ and hematologic malignancy groups. METHODS: Cancer patients with PTHrP-mediated hypercalcemia who were treated at Chonnam National University Hospital in Korea from January 2005 to January 2015 were retrospectively reviewed. RESULTS: Of all 115 patients, solid organ malignancies were the most common etiology (98 cases, 85.2%), with squamous cell carcinoma (50 cases, 43.4%), adenocarcinoma (27 cases, 23.4%). Interestingly, hepatocellular carcinoma (HCC; 18 cases, 15.7%) and cholangiocarcinoma (11 cases, 9.6%) were much more common causes than other previous reports. Hematologic malignancy was less common (17 cases, 14.8%), with multiple myeloma (9 cases, 7.8%) and non-Hodgkin's lymphoma (5 cases, 4.3%). Overall median survival was only 37 days. There was significant difference in median survival between two groups (35 days for solid organ malignancy and 72 days for hematologic malignancy; P=0.015). Cox regression analysis identified age, the type of malignancy and the time interval of developing hypercalcemia after cancer diagnosis as independent predictive factors for survival time. CONCLUSIONS: PTHrP-mediated hypercalcemia was most frequently caused by solid organ malignancy. However, HCC and cholangiocarcinoma were important causes of PTHrP-mediated hypercalcemia may be due to geographic differences in cancer incidence in Korean population. Age, the type of malignancy and the time interval of developing hypercalcemia after cancer diagnosis were independent poor predictive factors for survival time.

Does hepatobiliary phase sequence qualitatively outperform unenhanced T1-weighted imaging in assessment of the ablation margin 24 hours after thermal ablation of hepatocellular carcinomas?

PURPOSE: To retrospectively determine whether hepatobiliary phase (HBP) sequence outperforms unenhanced T1-weighted imaging (uT1wI) in distinguishing the ablation margin (AM) from hepatocellular carcinoma (HCC) 24 h after thermoablation. MATERIAL AND METHODS: Ninety-one patients [mean age, 65.7 years; 68 M/23F] with 138 HCCs (>6 months follow-up) underwent pre- and postablation gadoxetate disodium-enhanced MRI. AM showed a hyperintense middle zone (MZ) surrounding central hypo- or hyperintense HCCs on uT1wI, and an intermediate-intense MZ encompassing central hypo- or hyperintense HCCs during HBP. The visible AM was defined as persistent MZ around HCCs, which were demarcated from MZ, or peripherally band encompassing MZ, which were not demarcated from HCC. The indefinite AM was defined as no demarcating HCCs from MZ. The ability to distinguish AM from HCC was classified as visible or indefinite on axial (ax)-uT1wI, ax-HBP, coronal (cor)-HBP, and combined all images. To investigate the AM visibility during HBP, significance of differences upon comparison of ax-uT1wI with combined images was analyzed. Preablation liver-tumor contrast ratio (LTCR) on ax-uT1wI and ax-HBP sequence is compared between the visible and indefinite AM. RESULTS: The McNemar test demonstrated a significant increase (p < 0.05) in visible AM from ax-uT1wI (60), to ax-HBP (70), cor-HBP (79), and combined images (83). TLCR with visible AM was significantly higher than that with indefinite AM on ax-uT1wI (0.4 vs. 0.2, p = 0.001) and ax-HBP sequence (0.9 vs. 0.6, p = 0.004). CONCLUSIONS: HBP sequence might have higher feasibility to distinguish AM from tumor than ax-uT1wI. The TLCR value in visible AM was higher than that in indefinite AM on both ax-uT1wI and ax-HBP sequences.

Appendiceal Immunoglobulin G4-Related Disease Mimicking Appendiceal Tumor or Appendicitis: A Case Report.

Immunoglobulin G4 (IgG4)-related disease is an autoimmune disease that forms tumorous lesions. Several cases involving various organs are reported, however, IgG4-related disease involving appendix has not been reported yet. In this report, we presented a case of IgG4-related disease of appendix, which raised a suspicion of appendiceal tumor or usual appendicitis and, therefore, led to unnecessary surgical resection. IgG4-related disease should be considered in the differential diagnosis for a mass-like swelling of the appendix, in order to avoid unnecessary surgery.

Optimal cut-off value of perfusion parameters for diagnosing prostate cancer and for assessing aggressiveness associated with Gleason score.

To determine cut-off value of dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) parameters for differentiation of prostate malignant from benign and cancer with high-grade Gleason score (GS) (GS>7) from low-grade GS (GS≤7), 35 patients (24 malignant and 11 benign) who underwent DCE-MRI were included. Difference between malignant and benign was statistically significant for all magnetic resonance parameters except Ve. The cut-off values were K(trans)=0.184min(-1), Kep=0.695min(-1), iAUC=4.219mmol/l/min, and ADC=1340.5mm(2)/s. A significant difference in mean values of K(trans) and Kep between cancer with high-grade GS and low-grade GS was also observed. K(trans) and Kep showed a significant correlation with GS.

Temporal evolution of multidetector CT findings after endoscopic submucosal dissection in patients with early gastric cancer: correlation with endoscopy.

OBJECTIVE: To assess changes over time in imaging findings retrospectively by multidetector CT (MDCT) with two-dimensional (2D) multiplanar reconstruction and three-dimensional (3D) CT gastrography (CTG), after endoscopic submucosal dissection (ESD) in patients with early gastric cancer (EGC), and to correlate 3D CT images with endoscopic appearance. MATERIALS AND METHODS: In this retrospective study, a total of 84 patients underwent ESD and were followed up with MDCT. Fifteen patients underwent CT twice, and 3 patients underwent CT 3 times. A total of 105 CTs were included in this study and 43 CTs contained 3D CTGs. Two radiologists in consensus interpreted CT images for lesion detectability, presence and characteristics of ulcer, focal wall thickening, perigastric fat infiltration, and overlying enhancing layer in 2D images. The presence of ulcer or subtle mucosal nodularity, ulcer mound, and fold convergence were analysed in 3D CT images. We also assessed the time interval between ESD and CT and analysed the temporal evolution of CT findings. The sensitivity, specificity, and overall accuracy of 3D CTG were assessed regarding endoscopic features as the gold standard. RESULTS: The mean interval between ESD and follow up CT was 76.9 days (median, 62; range, 2-223). No tumour recurrence in any lesion was found on follow-up endoscopic biopsy and also lymph node or distant metastasis was not observed on CT exams in the follow-up period. The lesion detectability in a total of 105 post-ESD 2D CT images was 42.0% (44/105), and 93.2% (41/44) of the detected lesions were visualizable 2 months after ESD. Focal wall thickening was observed during the entire follow-up period in all patients. Perigastric fat infiltration was observed in 4 lesions within 1 week of ESD. Overlying enhancing layer appeared in 27 lesions without temporal evolution. On a total of 43 post-ESD 3D CTG, lesion detectability was 76.7% (33/43), and lesions could be visualized for a longer period than by 2D CT images (223 days versus 99 days). Three-dimensional imaging features revealed ulcer, ulcer mound, and fold convergence. Ulcer mounds disappeared first (median, 12.5 days; range, 2-14 days after ESD), ulcers appeared up to 4 months after ESD (median, 14 days; range, 2-174 days after ESD) and fold convergence continued to the end of the study (median, 74 days; range, 2-223 days after ESD). We found that sensitivity, specificity, and overall accuracy of 3D CTG were 70.0%, 92.9%, 83.3% for ulcer, 28.6%, 100%, 71.4% for ulcer mound, and 71.4%, 100%, 75% for fold convergence regarding endoscopy, respectively. CONCLUSION: On follow-up 2D or 3D CT images after ESD, early findings were of perigastric fat infiltration, ulcer, and surrounding oedema. Focal wall thickening and fold convergence continued to be observed late in the study. The overlying enhancing layer did not show temporal evolution.

Pelvic floor musculature and bladder neck changes before and after continence recovery after radical prostatectomy in pelvic MRI.

PURPOSE: To evaluate the changes in pelvic floor anatomy using MRI before and after continence recovery after radical prostatectomy (RP). MATERIALS AND METHODS: Thirteen men with prostate cancer who underwent RP (mean age, 67.4 ± 8.8 years) volunteered for this study. Prostate MRIs were performed during the preoperative (i), incontinent (ii), and continent (iii) periods. The membranous urethra length (MUL), puborectalis muscle (PRM) thickness, and the position of the bladder neck in relation to the pubic bone (Dx) and the pubococcygeous line (Dy) were measured. We compared all parameters in the preoperative, incontinent, and continent periods. RESULTS: MUL2 and MUL3 was significantly longer compared with MUL1, although no difference was found between MUL2 and MUL3. PRM3 thickness was significantly increased compared with PRM2 thickness. The Dx of the continence period was shorter than that of the incontinence period. The Dy of the continence period was longer than that of the incontinence period. CONCLUSION: The PRM thickened and the bladder neck moved upward and forward during the continence period. The changes in PRM thickness and the position of bladder neck may play an important role in the recovery of continence after RP.

The usefulness of computed tomographic colonography for evaluation of deep infiltrating endometriosis: comparison with magnetic resonance imaging.

OBJECTIVE: We wanted to assess the diagnostic value and morphologic feature of deep infiltrating endometriosis (DIE), involving rectosigmoid colon, with computed tomography (CT) colonography in comparison with magnetic resonance (MR). METHODS: Fifty patients with DIE, who had undergone CT colonography and MR imaging (MRI) before surgery, were enrolled. Among these 50 patients who underwent laparoscopic surgery with DIE, 37 patients were diagnosed as rectosigmoid involvement of endometriosis (presence of rectal outer wall involvement, endometrial implantation in the rectouterine space, and complete obliteration of cul-de-sac with histologic confirmation). Image findings at CT colonography and MRI were reviewed by 2 radiologists to determine whether there are radiologic features that can help predict rectosigmoid endometriosis. Computed tomography images were analyzed for the luminal alteration of rectosigmoid colon, mural thickening, and mass formation in the rectosigmoid colon, whereas MR images were analyzed for the mass formation in the rectosigmoid colon, fat plane obliteration, between rectum and uterus or vagina, retroversion of uterus, retraction of uterus toward the colon, and detection of endometrial spot in rectovaginal or rectouterine space. Statistical analysis was performed with Pearson χ and receiver operating characteristic curve. RESULTS: With CT colonography, the luminal alteration of rectosigmoid colon was detected with sensitivity of 96.0% and specificity of 48.0% (P < 0.001) in the overall rectosigmoid endometriosis and with sensitivity of 84.0% and specificity of 80.0% (P = 0.005) in the case of DIE with cul-de-sac obliteration. With MR, the sensitivity and specificity for detection of endometriosis of rectosigmoid or rectouterine space were 94.4% and 37.5% (P = 0.013), respectively. Other variables had no statistical significance. The diagnostic accuracy of CT colonography is higher than that of MRI (area under the curve, 0.786 vs 0.691; P < 0.001), for the overall rectosigmoid endometriosis. In the evaluation of complete cul-de-sac obliteration, morphologic change of rectosigmoid colon is identified more accurately with CT colonography than that of MRI (area under the curve, 0.821 vs 0.686; P < 0.001). CONCLUSIONS: Both CT colonography and MRI are highly sensitive to the detection of rectosigmoid endometriosis, but lack specificity. However, the depiction rate of morphologic change in rectosigmoid colon is greater with CT colonography than that of MRI, in the case of cul-de-sac obliteration. The luminal alteration significantly correlates with morphologic change in rectosigmoid endometriosis.

Inflammatory myofibroblastic tumor in colon.

Inflammatory myofibroblastic tumor (IMT) is an uncommon mesenchymal solid tumor commonly documented in children and young adults. Here, we report a case of IMT in colon confirmed pathologically after laparoscopic anterior resection. A 35-year-old man presented with anal bleeding after defecation for 2 weeks. Colonoscopy demonstrated a mass with shallow ulceration in the central area and irregular margin accompanied by intact mucosa in the descending colon. Computer tomography showed a well-demarcated and homogenous solitary mass in the descending colon. We performed laparoscopic anterior resection. This case was diagnosed as IMT after microscopic examination. The tumor was composed of a proliferation of spindle-shaped cells arranged in the hyaline material with chronic inflammatory cells, composed mainly of plasma cells and lymphocytes. Immunohistochemically, tumor cells were positive for smooth muscle actin, and vimentin, and negative for desmin, CD117 (c-kit), anaplastic lymphoma kinase-1.

Transient thyrotoxicosis accompanied by panhypopituitarism caused by ruptured Rathke's cleft cyst.

We describe a rare case of transient thyrotoxicosis secondary to painless thyroiditis accompanied by panhypopituitarism caused by ruptured Rathke's cleft cyst. A 32-year-old man presented with vomiting and diarrhea. Laboratory data showed that he had transient hypercalcemia, primary thyrotoxicosis due to painless thyroiditis and panhypopituitarism. The sellar magnetic resonance imaging showed cystic macroadenoma. He underwent surgical exploration. Histological examination showed a ruptured Rathke's cleft cyst. Our case suggests that, although rare, it is important to recognize the possibility of coexistence of hypopituitarism in patients with primary thyrotoxicosis.

Secondary omental infarction related to open and laparoscopic-assisted distal gastrectomy: report of two cases.

Omental infarction occurring after open and laparoscopic-assisted distal gastrectomy with partial omentectomy for gastric cancer was a very rare disease in the past, but its incidence has increased as more partial omentectomies are now being performed. But there are few case reports or radiologic studies on its increasing incidence. It is necessary to differentiate omental infarction from carcinomatosis peritonei, since both have similar imaging findings. In this report, we describe two cases of omental infarction; each occurred after open and laparoscopic-assisted distal gastrectomy in early gastric cancer patients. Partial omentectomy was performed in both cases. Omental infarction following distal gastrectomy with partial omentectomy can be discriminated from carcinomatosis peritonei by comparing with different initial and follow up CT findings.

Inhibition of osteoblastic differentiation by warfarin and 18-α-glycyrrhetinic acid.

Anticoagulation therapy with vitamin K antagonists such as warfarin is widely used to prevent and treat stroke in patients with chronic atrial fibrillation or mechanical heart valves. Because vitamin K is an essential factor for ggg-carboxylation of osteocalcin, vitamin K antagonists might cause bone loss. Although the association between warfarin use and bone metabolism is still controversial, several studies show that bone mineral density is decreased and fracture risk is increased with warfarin therapy. Meanwhile, attenuation of gap junctional communication (GJC) by warfarin is reported in rat liver epithelial cells. However, the effect of warfarin on osteoblasts, in which GJC is important for osteoblastic differentiation, remains unknown. Here we investigated whether warfarin has an inhibitory effect on osteoblastic differentiation using an osteoblastic cell line (C2C12). Warfarin and 18-α-glycyrrhetinic acid (AGA), which is known as a nontoxic reversible GJC inhibitor, had the same effect on osteoblastic differentiation. Warfarin and AGA inhibited the bone morphogenetic protein (BMP)2-induced mRNA levels of alkaline phosphatase (ALP), collagen I α1, osteocalcin (OC) and osterix, which are specific markers for osteoblastic differentiation, in a dose-dependent manner. Moreover, the activities of OC- and ALP-luciferase reporters, which are induced by BMP2, and the transcriptional activity of Runx2 on OC and ALP promoters were inhibited by warfarin and AGA. The amount and activity of ALP induced by BMP2 were also decreased by warfarin and AGA. These results suggest that warfarin and AGA, a GJC inhibitor, have an inhibitory effect on osteoblastic differentiation.