Analysis of the Clinical Course in a Population of Patients with Biliary Tract Cancer Diagnosed as Unresectable After Portal Vein Embolization: A Case Series.

Portal vein embolization (PVE) is recommended as a preoperative procedure for patients with biliary tract cancer scheduled to undergo hepatic resection of more than 50%-60% of the liver. However, details and/or information regarding the follow-up of unresectable cases are often lacking, and the clinical course of unresectable cases is not well analyzed and reported. This study aimed to clarify the clinical prognosis of patients with unresectable biliary tract cancer after PVE. We retrospectively analyzed the clinical backgrounds of patients with biliary tract cancer who underwent PVE without subsequent resection between January 2011 and October 2022. Of the 21 patients with biliary tract cancer who underwent PVE during the study period, eight (38%) cases were unsuitable for resection after PVE for the following reasons: intraoperatively detected dissemination (n=2), para-aortic lymph node metastasis (n=1), liver metastasis (n=1), decreased liver function (n=2), development of liver metastasis while waiting (n=1), and insufficient residual liver volume (n=1). All patients received subsequent chemotherapy, including gemcitabine plus S-1 therapy in three cases, gemcitabine plus cisplatin plus S-1 in three cases, and gemcitabine plus cisplatin or S-1+cisplatin in one case each. As there is currently no curative treatment for biliary tract cancer other than surgery, multidisciplinary management and treatment of patient factors, including tumor factors and liver function, are essential to reducing the number of unresectable cases after PVE.

A case of chylous ascites caused by reflux from the cisterna chyli to the disrupted common iliac lymphatic vessel: fluoroscopic records during intranodal lymphangiography.

A 40-year-old woman underwent laparoscopic common iliac lymphadenectomy for metastasis from rectal cancer. Two weeks after the surgery, she was found to have massive chylous ascites. After failure of conservative treatment, bilateral inguinal intranodal lymphangiography was performed. No definite extravasation was observed while lipiodol injected through the left inguinal node was ascending. When we punctured the right inguinal lymph nodes and started the injection of lipiodol, extravasation of diluted lipiodol was noted at the level of the first sacrum. Careful observation revealed that the ascending lipiodol became diluted in the cisterna chyli, refluxed through the median paraaortic route, leaked from the excised left common iliac lymph vessel, and flowed into the abdominal cavity. Lipiodol used in lymphangiography did not reduce chylous ascites at all. Twenty-seven days after lymphangiography, laparoscopic lymphatic ligation was performed, and the chylous ascites disappeared completely. CT obtained 40 days after surgical repair revealed disappearance of ascites and enlargement of the thoracic duct, which had not been observed on preoperative lymphangiography. Notably, lymphatic reflux from the cisterna chili can occur without obstruction of the thoracic duct and may result in chylous ascites.

Amide Proton Transfer-Chemical Exchange Saturation Transfer Imaging of Intracranial Brain Tumors and Tumor-like Lesions: Our Experience and a Review.

Chemical exchange saturation transfer (CEST) is a molecular magnetic resonance imaging (MRI) method that can generate image contrast based on the proton exchange between labeled protons in solutes and free, bulk water protons. Amide proton transfer (APT) imaging is the most frequently reported amide-proton-based CEST technique. It generates image contrast by reflecting the associations of mobile proteins and peptides resonating at 3.5 ppm downfield from water. Although the origin of the APT signal intensity in tumors is unclear, previous studies have suggested that the APT signal intensity is increased in brain tumors due to the increased mobile protein concentrations in malignant cells in association with an increased cellularity. High-grade tumors, which demonstrate a higher proliferation than low-grade tumors, have higher densities and numbers of cells (and higher concentrations of intracellular proteins and peptides) than low-grade tumors. APT-CEST imaging studies suggest that the APT-CEST signal intensity can be used to help differentiate between benign and malignant tumors and high-grade gliomas and low-grade gliomas as well as estimate the nature of lesions. In this review, we summarize the current applications and findings of the APT-CEST imaging of various brain tumors and tumor-like lesions. We report that APT-CEST imaging can provide additional information on intracranial brain tumors and tumor-like lesions compared to the information provided by conventional MRI methods, and that it can help indicate the nature of lesions, differentiate between benign and malignant lesions, and determine therapeutic effects. Future research could initiate or improve the lesion-specific clinical applicability of APT-CEST imaging for meningioma embolization, lipoma, leukoencephalopathy, tuberous sclerosis complex, progressive multifocal leukoencephalopathy, and hippocampal sclerosis.

Hepatic sclerosing haemangioma showing restricted diffusion: A case report with histopathologic correlation.

Hepatic sclerosing haemangiomas are rare benign tumours that are often difficult to distinguish from malignant tumours because these tumours do not show the typical imaging features of cavernous haemangiomas. We report a case of a sclerosing haemangioma that showed restricted diffusion and was difficult to differentiate from a malignancy. A 60-year-old female was referred to our hospital for evaluation of a hepatic mass that was incidentally diagnosed after a CT scan for right lower quadrant abdominal pain. Contrast-enhanced dynamic CT showed hepatic capsular retraction, with a small peripheral enhancement of the mass. The lesion appeared homogeneously hypointense on T1W images, heterogeneously hyperintense on T2W images, hyperintense on diffusion-weighted images, and hypointense on apparent diffusion coefficient (ADC) map. The lesion was suspected to be a cholangiocellular carcinoma and was surgically resected, but a final diagnosis of hepatic sclerosing haemangioma was made. Hepatic sclerosing/sclerosed haemangiomas are usually considered to show an increased ADC, which is useful for distinguishing them from malignant tumours. However, in this particular case, most of the lesion contained many obliterated or narrowed vascular channels, which might have acted as septa restricting the diffusion of water molecules in the intervening fibrous and/or hyalinised tissue. Hepatic sclerosing haemangiomas in the process of becoming completely fibrotic may show restricted diffusion, similar to malignant tumours.

Amide proton transfer MRI differentiates between progressive multifocal leukoencephalopathy and malignant brain tumors: a pilot study.

BACKGROUND: Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nerve system caused by the John Cunningham virus. On MRI, PML may sometimes appear similar to primary central nervous system lymphoma (PCNSL) and glioblastoma multiforme (GBM). The purpose of this pilot study was to evaluate the potential of amide proton transfer (APT) imaging for differentiating PML from PCNSL and GBM. METHODS: Patients with PML (n = 4; two men; mean age 52.3 ± 6.1 years), PCNSL (n = 7; four women; mean age 74.4 ± 5.8 years), or GBM (n = 11; 6 men; mean age 65.0 ± 15.2 years) who underwent APT-CEST MRI between January 2021 and September 2022 were retrospectively evaluated. Magnetization transfer ratio asymmetry (MTRasym) values were measured on APT imaging using a region of interest within the lesion. Receiver operating characteristics curve analysis was used to determine diagnostic cutoffs for MTRasym. RESULTS: The mean MTRasym values were 0.005 ± 0.005 in the PML group, 0.025 ± 0.005 in the PCNSL group, and 0.025 ± 0.009 in the GBM group. There were significant differences in MTRasym between PML and PCNSL (P = 0.023), and between PML and GBM (P = 0.015). For differentiating PML from PCNSL, an MTRasym threshold of 0.0165 gave diagnostic sensitivity, specificity, positive predictive value, and negative predictive value of 100% (all). For differentiating PML from GBM, an MTRasym threshold of 0.015 gave diagnostic sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 90.9%, 80.0%, and 100%, respectively. CONCLUSION: MTRasym values obtained from APT imaging allowed patients with PML to be clearly discriminated from patients with PCNSL or GBM.

Quantitative Chemical Exchange Saturation Transfer Imaging of Amide Proton Transfer Differentiates between Cerebellopontine Angle Schwannoma and Meningioma: Preliminary Results.

Vestibular schwannomas are the most common tumor at the common cerebellopontine angle, followed by meningiomas. Differentiation of these tumors is critical because of the different surgical approaches required for treatment. Recent studies have demonstrated the utility of amide proton transfer (APT)-chemical exchange saturation transfer (CEST) imaging in evaluating malignant brain tumors. However, APT imaging has not been applied in benign tumors. Here, we explored the potential of APT in differentiating between schwannomas and meningiomas at the cerebellopontine angle. We retrospectively evaluated nine patients with schwannoma and nine patients with meningioma who underwent APT-CEST MRI from November 2020 to April 2022 pre-operation. All 18 tumors were histologically diagnosed. There was a significant difference in magnetization transfer ratio asymmetry (MTRasym) values (0.033 ± 0.012 vs. 0.021 ± 0.004; p = 0.007) between the schwannoma and meningioma groups. Receiver operative curve analysis showed that MTRasym values clearly differentiated between the schwannoma and meningioma groups. At an MTRasym value threshold of 0.024, the diagnostic sensitivity, specificity, positive predictive value, and negative predictive values for MTRasym were 88.9%, 77.8%, 80.0%, and 87.5%, respectively. Our results demonstrated the ability of MTRasym values on APT-CEST imaging to discriminate patients with schwannomas from patients with meningiomas.

Long-term outcomes of living-donor liver transplantation, hepatic resection, and local therapy for hepatocellular carcinoma with three <3-cm nodules in a single institute.

Background and Aim: Treatment for small hepatocellular carcinoma (HCC) is determined based on the results of a liver function test and the tumor location and spread. The present study compared the outcomes among local therapy, hepatic resection (HR), and living-donor liver transplantation (LDLT) for small HCC in a single institute. Methods: We compared the overall survival, recurrence-free survival, and cancer-specific survival rates in patients with three HCC nodules <3 cm in size among local therapy, which included radiofrequency ablation (RFA), percutaneous ethanol injection (PEI), and transarterial chemoembolization (TACE), and surgical treatment (HR and LDLT). Results: One hundred and ninety-seven patients with local therapy (109 RFA, 26 PEI, and 78 TACE), 107 with HR, and 66 with LDLT were enrolled in this study. There was no significant difference in OS among these groups. The recurrence-free, cancer-specific survival (CSS) of LDLT was superior to local therapy and HR. The prognostic factors for the survival were Child-Pugh (CP) Grade B and tumor marker for local therapy and multiple tumors and elevated ALT levels for HR. Conclusions: For CP grade B patients with HCC of three <3-cm nodule, LDLT could be considered because it resulted in better survival and CSS rates than local therapy.

Successful pulmonary artery stenting for occlusion at a constructed pericardial conduit after right upper double sleeve lobectomy.

The patient was a 53-year-old man. His chief complaint was a cough and dyspnea on exertion. Computed tomography (CT) showed a 3-cm-diameter tumor in the right upper lobe with invasion from hilar lymph nodes to the superior vena cava, right main bronchus, and pulmonary artery. After being diagnosed with non-small cell lung cancer, the patient underwent preoperative induction radiochemotherapy. At surgery, right upper double sleeve lobe lobectomy was performed. The right main pulmonary artery was reconstructed using a pericardial conduit. CT 1 week after surgery showed impaired blood flow in the right pulmonary artery. A metal vascular stent was inserted into the narrow part of the constructed pulmonary artery in the hybrid operating room because thrombectomy was unsuccessful. After surgery, contrast CT showed that blood flow was maintained. The patient is currently well without any recurrence 3 years after surgery.

Successful retrograde transvenous embolization under balloon occlusion for rectal arteriovenous malformation.

A 57-year-old man was admitted to our hospital because of frequent hematochezia. Colonoscopy exhibited a submucosal tumor-like lesion in the lower rectum. Abdominal contrast-enhanced computed tomography showed a rectal arteriovenous malformation (AVM) on the right side wall of the lower rectum. The feeder was the superior rectal artery, with early venous return. Embolization of the draining vein and feeding artery of the AVM with N-butyl-2-cyanoacrylate under balloon occlusion was planned. Angiography of the superior rectal artery showed the nidus in the rectum with early venous return of contrast material. The portal vein was punctured percutaneously under ultrasound guidance, and a balloon catheter advanced to the distal part of the superior rectal vein. Venography under balloon occlusion showed the outflow vein and nidus. Transvenous and transarterial nidus embolization with N-butyl-2-cyanoacrylate under balloon occlusion was then performed. Since the embolization, there have been no further episodes of bleeding. There is no established treatment for AVMs. Successful treatment requires targeting and eradication of the nidus. We successfully performed embolization therapy for a rectal AVM via a retrograde transvenous approach. This technique may be suitable for completely eradicating the nidus without the risk of embolism.

Treatment of Periorbital and Palpebral Arteriovenous Malformations.

Objectives: To clarify clinically challenging palpebral arteriovenous malformations (AVMs) and to propose a novel therapeutic modality, we developed a multi-disciplinary approach for the management of AVMs with ulcer. Approach: First, the central retinal artery was secured with embolization by the transophthalmic arterial, a terminal branch of the internal carotid artery (ICA), and then, the branches of the external carotid artery (ECA) were embolized to cause a response in the AVM vasculature followed by sclerotherapy and surgery. Results: Over a 3-year follow-up of palpebral and periorbital AVMs in four females and one male 20 to 50 years of age with a mean age of 38 years, complete remission of the lesions were seen with no major complication, such as blindness, ptosis, or cerebral infarction, with functionally sound and esthetically acceptable results, with no recurrence or worsening even with one case of ulceration postembolization. Innovation: Planned treatment of palpebral and periorbital AVMs, which have been often left untreated because of their complex vasculature and a risk of total blindness due to occlusion of the central retinal artery. A "wait-and-watch" approach is frequently taken. It is important to secure the periphery to the bifurcation of the central retinal artery of the ICA, and then, embolization through the ECA results in complete remission of the lesion, followed by sclerotherapy and surgery, which are successful both in terms of function and esthetics. Conclusion: First, securing the central retinal artery leads to safer and complete resolution of palpebral and periorbital AVMs; wounding or therapeutic complications such as skin necrosis may be seen, but this approach results in complete remission in 3 years with no major complications.

Cerebral lipiodol embolism related to a vascular lake during chemoembolization in hepatocellular carcinoma: A case report and review of the literature.

A male patient underwent conventional transcatheter chemoembolization for advanced recurrent hepatocellular carcinoma (HCC). Even after the injection of 7 mL of lipiodol followed by gelatin sponge particles, the flow of feeding arteries did not slow down. A repeat angiography revealed a newly developed vascular lake draining into systemic veins; however, embolization was continued without taking noticing of the vascular lake. The patient's level of consciousness deteriorated immediately after the procedure, and non-contrast computed tomography revealed pulmonary and cerebral lipiodol embolisms. The patient's level of consciousness gradually improved after 8 wk in intensive care. In this case, a vascular lake emerged during chemoembolization and drained into systemic veins, offering a pathway carrying lipiodol to pulmonary vessels, the most likely cause of this serious complication. We should be aware that vascular lakes in HCC may drain into systemic veins and can cause intratumoral arteriovenous shunts.

Arterial injury during transcatheter arterial chemoembolization for hepatocellular carcinoma: predictors of risk and outcome.

PURPOSE: To investigate clinical features and results of follow-up in patients with arterial injury during transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma. METHODS: From 2005 to 2015, 2219 TACE procedures were performed in 906 patients in our hospital. Iatrogenic arterial injury occurred during 38 TACE procedures (sessions) in 35 patients (24 men, 11 women; mean age 71.8 years). The incidence of arterial injury was 1.7%. We evaluated the characteristics of arterial injury, and evaluated the risk factors for incomplete recanalization of the injured artery at follow-up angiography conducted after 1-11 months (mean 102.5 days). RESULTS: Iatrogenic arterial injury was caused by the microcatheter in 34 of 38 cases (86.8%). There were 15 cases (39.5%) in which the replaced hepatic artery or the extrahepatic artery was the parasitic supply. Extravasation occurred in five cases. In 36 of 38 cases, follow-up angiography was performed. We divided 36 cases into two groups: complete reopening (n = 24) and non-complete reopening (n = 12). The two groups were compared regarding the factors associated with incomplete recanalization of the injured artery at follow-up. Injury length >3 cm (p = 0.0002) and proximal arterial injury (proximal to the segmental artery; p = 0.03) were significant risk factors for non-complete reopening of the injured artery. CONCLUSION: Iatrogenic arterial injury frequently occurred in the extrahepatic artery or replaced hepatic artery. Recanalization rate of arterial injury was high; however, injury length >3 cm and proximal arterial injury were risk factors for non-complete reopening of the injured artery.

Local recurrence after chemoembolization of hepatocellular carcinoma: uptake of gadoxetic acid as a new prognostic factor.

OBJECTIVE: The purpose of this article is to investigate whether there is a difference in susceptibility to transcatheter arterial chemoembolization between hepatocellular carcinomas (HCCs) showing high uptake and those showing low uptake of gadoxetic acid in the hepatobiliary phase of MRI. MATERIALS AND METHODS: One hundred HCCs that achieved optimal chemoembolization, as assessed by immediate CT in 60 patients, were classified as having high (n = 19) or low (n = 81) uptake of gadoxetic acid on MRI performed before chemoembolization. The local recurrence rates were estimated using the Kaplan-Meier method, and differences between the groups were compared using the log-rank test. The following factors were also correlated with the local recurrence rate using the Cox proportional hazards model for a univariate analysis: high uptake of gadoxetic acid, number of feeding arteries, extrahepatic arterial supply, Child-Pugh class, clinical tumor stage, size, location, and iodized oil accumulation in the noncancerous tissue surrounding the lesion. Parameters that were significant at p < 0.05 were entered into a multivariate model. RESULTS: The 1- and 3-year local recurrence-free rates were 95% in high-uptake HCCs and 66% and 54%, respectively, in low-uptake HCCs (log-rank test, p < 0.01). The low uptake of gadoxetic acid was the only significant predictor of early local recurrence (hazard ratio = 9.24; p = 0.03) by multivariate analysis. CONCLUSION: HCCs showing high uptake of gadoxetic acid appear to be susceptible to chemoembolization.

Peri-stent aneurysm formation following a stent implant for stenotic intracranial vertebral artery dissection: a technical report of two cases successfully treated with coil embolization.

INTRODUCTION: Although stenting for stenotic vertebral artery dissection (VAD) improves compromised blood flow, subsequent peri-stent aneurysm (PSA) formation is not well-known. We report two cases with PSA successfully treated with coil embolization. METHODS: Three patients with stenotic intracranial VAD underwent endovascular angioplasty at our institution because they had acute infarction in posterior circulation territory and clinical evidence of hemodynamic insufficiency. In two of three patients balloon angioplasty at first session failed to relieve the stenosis, and a coronary stent was implanted. Angiography immediately after stenting showed no abnormality in case 1 and minimal slit-like projection at proximal portion of the stent in case 2. RESULTS: Angiography obtained 16 months after the stenting revealed PSA in case 1. In case 2, angiography performed 3 months later showed that the projection at proximal portion enlarged and formed an aneurysm outside the stent. Because follow-up angiographies showed growth of the aneurysm in both cases, endovascular aneurysmal embolization was performed. We advanced a microcatheter into the aneurysm through the strut of existing stent and delivered detachable coils into the aneurysm lumen successfully in both cases. The post-procedural course was uneventful, and complete obliteration of aneurysm was confirmed on angiography in both cases. CONCLUSION: Stenting for stenotic intracranial VAD may result in delayed PSA; therefore, follow-up angiographies would be necessary after stenting for stenotic intracranial arterial dissection. Coil embolization through the stent strut would be a solution for enlarging PSA.

Percutaneous radiofrequency ablation and transcatheter arterial chemoembolization for hypervascular hepatocellular carcinoma: rate and risk factors for local recurrence.

PURPOSE: To analyze local recurrence-free rates and risk factors for recurrence following percutaneous radiofrequency ablation (RFA) or transcatheter arterial chemoembolization (TACE) for hypervascular hepatocellular carcinoma (HCC). METHODS: One hundred and nine nodules treated by RFA and 173 nodules treated by TACE were included. Hypovascular nodules were excluded from this study. Overall local recurrence-free rates of each treatment group were calculated using the Kaplan-Meier method. The independent risk factors of local recurrence and the hazard ratios were analyzed using Cox's proportional-hazards regression model. Based on the results of multivariate analyses, we classified HCC nodules into four subgroups: central nodules < or =2 cm or >2 cm and peripheral nodules < or =2 cm or >2 cm. The local recurrence-free rates of these subgroups for each treatment were also calculated. RESULTS: The overall local recurrence-free rate was significantly higher in the RFA group than in the TACE group (p = 0.013). The 24-month local recurrence-free rates in the RFA and TACE groups were 60.0% and 48.9%, respectively. In the RFA group, the only significant risk factor for recurrence was tumor size >2 cm in greatest dimension. In the TACE group, a central location was the only significant risk factor for recurrence. In central nodules that were < or =2 cm, the local recurrence-free rate was significantly higher in the RFA group than in the TACE group (p < 0.001). In the remaining three groups, there was no significant difference in local recurrence-free rate between the two treatment methods. CONCLUSION: A tumor diameter of >2 cm was the only independent risk factor for local recurrence in RFA treatment, and a central location was the only independent risk factor in TACE treatment. Central lesions measuring < or =2 cm should be treated by RFA.

Proton MR spectroscopy and diffusion-weighted MR imaging for the diagnosis of intracranial tuberculomas. Report of two cases.

With the current prevalence of tuberculosis, the incidence of intracranial tuberculoma may be on the rise in industrialized nations. However, clinical findings suggestive of systemic tuberculosis are frequently subtle or absent in patients with intracranial tuberculoma, and no specific neuroradiologic characteristics of tuberculoma have been defined as yet. We report two cases of ring-enhanced intracranial tuberculoma in which magnetic resonance (MR) proton spectroscopy and diffusion-weighted (DW) imaging were useful in the differential diagnosis between tuberculoma and other ring-enhanced mass lesions. Pulmonary tuberculosis had been diagnosed in one patient, but radiologic lung study and tuberculin skin test were negative in the other. DW imaging showed bright signal intensity in the core of all lesions in both patients. Malignant gliomas and metastatic brain tumors do not have this characteristic. Proton MR spectroscopy of lesion cores showed lipid peaks and a choline peak in one, and a lipid/lactate mixture pattern in the other, which differed distinctively from those of the pyogenic brain abscess. in each case, one lesion was surgically removed. Antituberculosis drugs were started before surgery for one patient and after surgery for the other. In both, the remaining lesions were reduced significantly in size. We discuss the diagnostic potential of these MR techniques and management options of intracranial tuberculoma.