Fetal Hepatic Hemangioma Diagnosed in Utero Using Doppler Microvascular Imaging.

A 35-year-old pregnant woman was referred to our institution at 33 weeks' gestation for evaluation of a fetal abdominal tumor. B-mode ultrasonography demonstrated a massive lesion. Bidirectional power Doppler mode showed abundant blood flow surrounding the tumor. On superb micro-vascular imaging, various Doppler signal patterns were observed within the tumor, including diffuse fine dotted-like signals, linear flow, and internal shunt flow. Sequential observations of the tumor and cardiac cycles also revealed pulsatile flow beneath the edges of the tumor and continuous fine flow in the central area, resembling a 'centripetal fill-in' appearance on contrast computed tomography. Therefore, we assumed the fetal tumor to be a hepatic hemangioma. Fetal heart failure was detected at 37 weeks' gestation, and a 2,484-g female infant was delivered with 1- and 5-min Apgar scores of 7 and 8, respectively. A postnatal contrast computed tomography examination showed a progressive centripetal fill-in appearance, leading to a diagnosis of hepatic hemangioma. Kasabach-Merritt syndrome was also noted. Intensive treatment was performed, and the infant was discharged at 3 months after birth. In summary, we experienced a case of hepatic hemangioma diagnosed in utero using superb micro-vascular imaging. And basing seamless postnatal treatments on prenatal imaging findings may help to reduce the perinatal mortality.

Successful Superficial Blood Sampling to Localize a Fibroblast Growth Factor-23-Producing Tumor.

BACKGROUND Tumor-induced osteomalacia (TIO) is a paraneoplastic syndrome caused by aberrant fibroblast growth factor-23 (FGF-23)-producing tumors. Early surgical resection is the optimal strategy for preventing TIO progression. Thus, tumor localization is a priority for successful treatment. A simple and safe examination method to identify functional endocrine tumors is essential to achieve better outcomes in patients with TIO. CASE REPORT A 64-year-old Japanese man with recurrent fractures, hypophosphatemia, and elevated alkaline phosphatase and FGF-23 levels (109 pg/mL) was admitted to our university hospital and was diagnosed with FGF23-related hypophosphatemic osteomalacia. Notably, the superficial dorsal vein in the patient's left foot exhibited a high FGF-23 level (7510 pg/mL). Octreotide and ¹8F-fluorodeoxyglucose (FDG) scintigraphy and systemic venous sampling revealed that the tumor in the third basal phalanx of the left foot was responsible for FGF-23 overproduction. Tumor resection resulted in a rapid decrease in serum FGF-23 levels and an increase in serum phosphorus levels. CONCLUSIONS Octreotide scintigraphy, FDG-positron emission tomography, and systemic venous sampling are the standard methods for localizing functional endocrine tumors. However, the limited availability and invasive nature of these examinations hinder effective treatment. Here, we highlight the importance of peripheral superficial blood sampling as an alternative to conventional systemic methods for confirming the presence of FGF-23-producing tumors. Clinicians should consider TIO as a potential cause of acquired hypophosphatemic osteomalacia. Furthermore, peripheral superficial vein blood sampling may be useful for confirming the localization of FGF-23-producing tumors.

Utility of non-contrast-enhanced magnetic resonance imaging in predicting preoperative clinical stage and prognosis in patients with thymic epithelial tumor.

PURPOSE: The purpose of this study was to find useful imaging features on non-contrast-enhanced magnetic resonance imaging (MRI) that can divide patients with thymic epithelial tumor (TET) into clinical stage I-II and III-IV groups under assumption that contrast media are contraindicated. MATERIALS AND METHODS: This retrospective study included 106 patients (median age, 60 years; range, 27-82 years; 62 women) with surgically resected TET who underwent MRI between August 1986 and July 2015. All cases were classified according to the 2015 WHO classification and staged using the eighth edition of the TNM system. Two radiologists independently evaluated 14 categories of MRI findings; the findings in patients with stage I-II were compared with those of patients with stage III-IV using a logistic regression model. Disease-specific survival associated with significant findings was calculated using the Kaplan-Meier method. RESULTS: Univariate analysis showed that stage III-IV patients were more likely to have tumors with an irregular contour, heterogeneity on T1WI, low-signal intensity on T2WI, irregular border with lung, findings of great vessel invasion (GVI) (hereafter, GVI sign), pericardial thickening/nodule, and lymphadenopathy (all, P < 0.01). On multivariable analysis, only two findings, irregular border between tumor and lung (odds ratio [OR], 272.8; 95% CI 26.6-2794.1; P < 0.001) and positive GVI sign (OR, 49.3; 95% CI 4.5-539.8; P = 0.001) remained statistically significant. Patients with one or both features had significantly worse survival (log-rank test, P < 0.001). CONCLUSION: For patients with TET who are unable to receive contrast for preoperative staging, the two image findings of an irregular border between tumor and lung and the positive GVI sign on non-contrast-enhanced MRI could be helpful in determining stage III-IV disease which is associated with a worse survival.

T1 invasive lung adenocarcinoma: Thin-section CT solid score and histological periostin expression predict tumor recurrence.

Adenocarcinoma is the most common histological type of non-small cell lung cancer (NSCLC), and various biomarkers for predicting its prognosis after surgical resection have been suggested, particularly in early-stage lung adenocarcinoma. Periostin (also referred to as POSTN, PN or osteoblast-specific factor) is an extracellular matrix protein, the expression of which is associated with tumor invasiveness in patients with NSCLC. In the present study, the novel approach, in which the thin-section CT findings prior to surgical resection and periostin expression of resected specimens were analyzed in combination, was undertaken to assess whether the findings could be a biomarker for predicting the outcomes following resection of T1 invasive lung adenocarcinoma. A total of 73 patients who underwent surgical resection between January 2000 and December 2009 were enrolled. A total of seven parameters were assessed in the thin-section CT scans: i) Contour; ii) part-solid ground-glass nodule or solid nodule; iii) percentage of solid component (the CT solid score); iv) presence of air-bronchogram and/or bubble-like lucencies; v) number of involved vessels; vi) shape linear strands between the nodule and the visceral pleura; and vii) number of linear strands between the nodule and the visceral pleura. Two chest radiologists independently assessed the parameters. Periostin expression was evaluated on the basis of the strength and extent of staining. Univariate and multivariate analyses were subsequently performed using the Cox proportional hazards model. There was a substantial to almost perfect agreement between the two observers with regard to classification of the seven thin-section CT parameters (κ=0.64-0.85). In the univariate analysis, a CT solid score >80%, pathological lymphatic invasion, tumor and lymph node status and high periostin expression were significantly associated with recurrence (all P<0.05). Multivariate analysis demonstrated that a CT solid score >80% and high periostin expression were risk factors for recurrence (P=0.002 and P=0.011, respectively). The cumulative recurrence rates among the three groups (both negative, CT solid score >80% or high periostin expression, or both positive) were significantly different (log-rank test, P<0.001). Although the solid component is already known to be a major predictor of outcome in lung adenocarcinomas according to previous studies, the combined analysis of CT solid score and periostin expression might predict the likelihood of tumor recurrence more precisely.

Successful treatment of a patient with chyluria due to lymphangioleiomyomatosis using sirolimus.

Lymphangioleiomyomatosis (LAM) is a rare and progressive neoplastic disease of young woman, characterized by the proliferation of abnormal smooth muscle-like cells (LAM cells) in the lungs and axial lymphatics. A 44-year-old woman was referred to our hospital because pleural effusion was detected during a health checkup. She had chylothorax, chylous ascites, and chyluria, and her computed tomography scan showed a solid tumor in the pelvis. Surgical biopsy was performed; she was diagnosed as having LAM. We could not control the fluid collection and chyluria using standard medical treatments. Therefore, we chose to administer sirolimus, and her symptoms dramatically improved. The mechanism of chyluria presumably involved LAM cell infiltrates in the ureter via the lymphatic vessel flow, which causes LAM to develop because of ureter wall exposure.

Emergent interventional approach for aortogastric tube fistula with massive gastrointestinal bleeding.

This report describes the successful endovascular treatment of a rare case of aortogastric tube fistula with massive gastrointestinal haemorrhage. The patient's history included oesophageal reconstruction for oesophageal carcinoma using a gastric tube. Emergent angiography revealed extravasation from the thoracic aorta into the thinner aortogastric tube fistula. A microcatheter was inserted into the aortogastric tube with the aortic approach for embolisation with a mixture of n-butyl cyanoacrylate and iodised oil to enable fluoroscopic visualisation. Aortography confirmed the complete absence of extravasation after embolisation, after which a stent graft was placed. This procedure demonstrated that transcatheter embolisation of the aortogastric tube fistula was possible, and that the technique can be used as an emergency option. CT imaging was performed 21 days after the procedure, and revealed no trace of extravasation or inflammation. There were no complications during the 14 months following the endovascular treatment; the patient remains in stable condition.

Management of visceral artery embolization using 0.010-inch detachable microcoils.

Transcatheter coil embolization is used primarily to treat arterial hemorrhages, tumors, aneurysms, and vascular malformations. However, conventional microcatheter systems cannot always be employed in difficult cases. In this technical note, we describe how small-diameter primary coils and microcatheter tips that are thinner than normal can be used to increase the safety and reliability of coil embolization.

A newly developed double lumen microballoon catheter with a side hole: initial experience of intraarterial infusion chemotherapy and/or embolization.

PURPOSE: To introduce a newly developed double lumen microballoon catheter with a side hole for intraarterial infusion chemotherapy and/or embolization. METHODS AND MATERIALS: Seven patients with malignant tumors, for whom superselective catheterization was considered difficult or had failed, underwent intraarterial infusion chemotherapy and/or embolization with the 3.3-Fr microballoon catheter. The catheter has a double lumen and a side hole to facilitate infusion from the proximal end of the balloon. The balloon was placed on the distal side of the target artery branching site. Inflation of the balloon and occlusion of the main lumen with the tip of the occlusion device allowed for intraarterial infusion chemotherapy and/or embolization of the target artery via the side hole. RESULTS: Successful intraarterial infusion chemotherapy and/or embolization with the microballoon catheter was performed in all patients with no complications. CONCLUSIONS: The newly developed microballoon catheter achieves intraarterial infusion chemotherapy and/or embolization without the need for superselective catheterization.

Ultraselective arterial embolization of vasa recta using 1.7-French microcatheter with small-sized detachable coils in acute colonic hemorrhage after failed endoscopic treatment.

OBJECTIVE: The purpose of this article is to document our experiences with ultraselective arterial embolization to manage acute colonic hemorrhage using a 1.7-French microcatheter with small-sized detachable coils and to discuss the feasibility and clinical efficacy of this new technique. CONCLUSION: We achieved technical success in all four patients with the sole use of short-segment embolization of the long branch of the vasa recta. Our findings suggest that this technique is useful for embolization in cases of colonic hemorrhage.

Hepatic arterial infusion chemotherapy with a coaxial reservoir system using a non-braided spiral tip microcatheter.

PURPOSE: To evaluate the efficacy and safety of a coaxial reservoir system with a non-braided spiral tip microcatheter and exclusive port for hepatic arterial infusion chemotherapy. MATERIALS AND METHODS: In vitro evaluation included evaluation of pressure tolerance/flow rate of the coaxial reservoir system, and the strength of connection between the 2.7-F catheter and port. Due to the difficulty of implanting conventional reservoirs, coaxial reservoirs were implanted via the femoral artery of 80 patients. We implanted a non-braided 2.7-F microcatheter with a spiral shaped tip, 5-F catheter, and a port. Clinical assessment included evaluation of technical success and complications. RESULTS: In vitro evaluation of the coaxial reservoir at its maximum pressure load showed that flow rates for 300 mg I/mL iopamidol contrast medium were 0.25 ± 0.04 mL/s (undiluted), 1.03 ± 0.01 mL/s (50% dilution), and 2.91 ± 0.01 mL/s (30% dilution). Connection strength between the 2.7-F catheter and port was 13.4 ± 0.57 N. Percutaneous port catheter placement was successful in all patients (100%, n = 80). Complications included hepatic arterial occlusion (10%, n = 8), catheter tip dislocation (1.3%, n = 1), and catheter occlusion (1.3%, n = 1). CONCLUSIONS: A coaxial reservoir system with a non-braided microcatheter and exclusive port is safe and effective for difficulty of implanting conventional reservoir.

Four cases of acute epiglottitis with a peritonsillar abscess.

We report four cases of acute epiglottitis with a peritonsillar abscess originating from the inferior pole of the palatine tonsil. All cases were male, and presented with acute onset of sore throat and dysphagia. Flexible laryngoscopy revealed swollen epiglottis and swelling at the base of tongue along the edge of the epiglottis in all cases. Computed tomography (CT) revealed the position and extent of a peritonsillar abscess. Surgical drainage was not performed. Abscesses decreased in size following intravenous antibiotics and corticosteroids. We surmise that inflammatory exudates extending widely in the pre-epiglottic space cause epiglottic swelling from oropharyngeal infection, the latter of which is thought to produce a peritonsillar abscess. We recommend CT examination for patients with a stable airway and swollen epiglottis, even if the swelling is mild. This will allow for exclusion of deep neck abscess and determination of the most effective treatment including intravenous antibiotics against anaerobe, incision and drainage of an abscess.

Arterial catheterization and embolization for management of emergent or anticipated massive obstetrical hemorrhage.

PURPOSE: The aim of this study was to evaluate the indications, efficacy, and safety of arterial catheterization and embolization for the management of emergent or anticipated massive obstetrical hemorrhage and its effects on menses and fertility. MATERIALS AND METHODS: Eighteen patients underwent arterial catheterization and embolization for intractable obstetrical hemorrhage between January 2001 and December 2005. Three groups of patients were identified: group 1 (n = 6) experienced postpartum hemorrhage; group 2 (n = 5) had anticipated severe postpartum hemorrhage; and group 3 (n = 7) had a risk factor for anticipated severe hemorrhage after dilation and evacuation. Gynecological information after embolization was obtained from medical records and telephone interviews. RESULTS: All patients in group 1 had a favorable outcome after treatment with a single embolization. All patients in group 2 had a placenta previa with an estimated blood loss of 1215-3250 ml. In group 3, bleeding was controlled in six patients; one patient had a hysterectomy because embolization was not possible. There were no short-or long - term complications, and normal menstruation resumed. Four patients became pregnant after embolization. CONCLUSION: Arterial catheterization and embolization is an effective, safe method for treating intractable obstetrical hemorrhage and might eliminate the need for hysterectomy and maintain reproductive ability.

[Intra-arterial cellular immunochemotherapy for unresectable pancreatic cancer with liver metastasis].

PURPOSE: To date, no treatment has had a significant impact on pancreatic cancer with liver metastasis. We performed locoregional cellular immunochemotherapy for unresectable pancreatic cancer with liver metastasis. SUBJECTS AND METHODS: A 71-year-old man was diagnosed for unresectable stage IVb pancreatic cancer. This patient was given intra-arterial infusion of gemcitabine (GEM) 400 mg/body and intravenous infusion GEM 600 mg/body, simultaneously. The day after GEM infusion, he was given intra-arterial autologous tumor cell activated T lymphocytes (AuTL). RESULTS: Tumor markers, such as CEA and CA19-9, had decreased a little. Primary tumor and metastatic liver tumor were reduced, but he died due to intra-abdominal dissemination within 5 months after diagnosis of unresectable pancreatic cancer. CONCLUSIONS: Reduced primary pancreatic tumor and metastatic liver tumor was obtained by locoregional cellular immunochemotherapy. But we could not control intra-abdominal dissemination. In conclusion, we suggest that intra-abdominal AuLT infusion in combination with intra-arterial AuLT infusion may be advisable to patients for unresectable pancreatic carcinoma with intra-abdominal dissemination.

[Intra-arterial chemotherapy with gemcitabine (GEM) for unresectable pancreatic cancer].

PURPOSE: Most patients with pancreatic cancer are unresectable because of local invasion and liver metastasis at the time of diagnosis. To date, no treatment has had a significant impact on this disease. To deliver a high concentration of drug to the cancer, intra-arterial chemotherapy with GEM was performed in two patients with unresectable advanced cancer. PATIENTS AND METHODS: One patient, a 70-year-old man with liver metastasis, was treated with arterial infusion of GEM 1,000 mg/body. Another patient, a 55-year-old woman with local invasion and distant metastatic lymphadenopathy, was given intra-arterial infusion of GEM 400 mg and intra-venous infusion of GEM 1,000 mg/body. The patients were given GEM weekly for 3 weeks followed by a week of rest. RESULTS: In the first patient, the pain went away and CEA was decreased for 6 months. After that, the patient died due to intra-abdominal dissemination within 4 months. In the other patient, the pain went away. Tumor markers, such as CEA and CA19-9, were normalized and primary pancreatic cancer was reduced locally. The patient currently has a metastatic liver tumor, but she has had a significant improvement in performance status. CONCLUSION: Intra-arterial chemotherapy with GEM may be tolerated in patients with unresectable pancreatic cancer.