3-Fr steerable microcatheter system via the upper limb artery in RADPLAT for right maxillary cancer.

BACKGROUND: To evaluate the efficacy of a catheter system using a 3-Fr sheath with a steerable microcatheter through right upper limb artery access for superselective intra-arterial cisplatin infusion and concomitant radiotherapy (RADPLAT) to treat right maxillary sinus squamous cell carcinoma (MS-SCC). MATERIAL AND METHODS: We retrospectively studied 46 sessions in eight patients treated between November 2020 and February 2023 using the catheter system briefly described below. A 3-Fr sheath was inserted into the distal radial, conventional radial, or brachial arteries. A coaxial catheter system with a 2.9-Fr steerable microcatheter and a 1.9-Fr microcatheter was advanced into the brachiocephalic artery. The right common carotid artery was selected by bending the tip of the steerable microcatheter. Coil embolization and intra-arterial cisplatin infusion after selecting each external carotid artery branch were achieved using this catheter system. RESULTS: Cisplatin infusion and coil embolization were successful in all sessions. Arterial occlusion at the sheath insertion sites was found in 29.4% (5/17) of the distal radial arteries and 33.3% (3/9) of the conventional radial arteries. No other major complications were observed during the procedure. CONCLUSION: Using a 3-Fr catheter system with a steerable microcatheter through right upper limb artery access is a feasible method for RADPLAT in treating right MS-SCC.

Evaluation of Uterine Carcinosarcoma and Uterine Endometrial Carcinoma Using Magnetic Resonance Imaging Findings and Texture Features.

Aim  This study aimed to evaluate the diagnostic feasibility of magnetic resonance imaging (MRI) findings and texture features (TFs) for differentiating uterine endometrial carcinoma from uterine carcinosarcoma. Methods This retrospective study included 102 patients who were histopathologically diagnosed after surgery with uterine endometrial carcinoma (n=68) or uterine carcinosarcoma (n=34) between January 2008 and December 2021. We assessed conventional MRI findings and measurements (cMRFMs) and TFs on T2-weighted images (T2WI) and apparent diffusion coefficient (ADC) map, as well as their combinations, in differentiating between uterine endometrial carcinoma and uterine carcinosarcoma. The least absolute shrinkage and selection operator (LASSO) was used to select three features with the highest absolute value of the LASSO regression coefficient for each model and construct a discriminative model. Binary logistic regression analysis was used to analyze the disease models and conduct receiver operating characteristic analyses on the cMRFMs, T2WI-TFs, ADC-TFs, and their combined model to compare the two diseases. Results A total of four models were constructed from each of the three selected features. The area under the curve (AUC) of the discriminative model using these features was 0.772, 0.878, 0.748, and 0.915 for the cMRFMs, T2WI-TFs, ADC-TFs, and a combined model of cMRFMs and TFs, respectively. The combined model showed a higher AUC than the other models, with a high diagnostic performance (AUC=0.915). Conclusion A combined model using cMRFMs and TFs might be helpful for the differential diagnosis of uterine endometrial carcinoma and uterine carcinosarcoma.

Progressive metastatic pheochromocytoma induced by multiple endocrine neoplasia type 2A with a lethal outcome.

Introduction: Patients with multiple endocrine neoplasia type 2A (MEN2A) harboring a pathological variant in the RET gene are characterized by medullary thyroid carcinoma (MTC), pheochromocytoma, and hyperparathyroidism. Although pheochromocytoma is currently defined as a malignant tumor, MEN2A-associated pheochromocytoma is known to have a small risk of metastasis. Case presentation: The case was a 62-year-old Japanese male with bilateral pheochromocytoma, multiple metastases in the liver and bones, and a cardiac thrombus. Genetic testing revealed a pathological variant at codon 634 of the RET gene, thereby leading a diagnosis of MTC. We considered that the multiple metastases were due to MTC; however, a liver biopsy revealed metastasis of pheochromocytoma. Conclusion: When pheochromocytoma precedes MTC, the diagnosis of MEN2A may be difficult.

Diagnostic utility of a conventional MRI-based analysis and texture analysis for discriminating between ovarian thecoma-fibroma groups and ovarian granulosa cell tumors.

OBJECTIVE: To evaluate the diagnostic utility of conventional magnetic resonance imaging (MRI)-based characteristics and a texture analysis (TA) for discriminating between ovarian thecoma-fibroma groups (OTFGs) and ovarian granulosa cell tumors (OGCTs). METHODS: This retrospective multicenter study enrolled 52 patients with 32 OGCTs and 21 OTFGs, which were dissected and pathologically diagnosed between January 2008 and December 2019. MRI-based features (MBFs) and texture features (TFs) were evaluated and compared between OTFGs and OGCTs. A least absolute shrinkage and selection operator (LASSO) regression analysis was performed to select features and construct the discriminating model. ROC analyses were conducted on MBFs, TFs, and their combination to discriminate between the two diseases. RESULTS: We selected 3 features with the highest absolute value of the LASSO regression coefficient for each model: the apparent diffusion coefficient (ADC), peripheral cystic area, and contrast enhancement in the venous phase (VCE) for the MRI-based model; the 10th percentile, difference variance, and maximal correlation coefficient for the TA-based model; and ADC, VCE, and the difference variance for the combination model. The areas under the curves of the constructed models were 0.938, 0.817, and 0.941, respectively. The diagnostic performance of the MRI-based and combination models was similar (p = 0.38), but significantly better than that of the TA-based model (p < 0.05). CONCLUSIONS: The conventional MRI-based analysis has potential as a method to differentiate OTFGs from OGCTs. TA did not appear to be of any additional benefit. Further studies are needed on the use of these methods for a preoperative differential diagnosis of these two diseases.

Schwannoma in and around the porta hepatis: radiological features in eight cases and literature review.

PURPOSE: Schwannomas in and around the porta hepatis (porta hepatic schwannomas) are rare benign tumors easily misdiagnosed as other pathologies, including malignancies. We aimed to evaluate their imaging features on ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and 18F-fluorodeoxyglucose-positron emission tomography/CT (FDG-PET/CT). METHODS: We performed a multi-institutional retrospective study by reviewing the clinical and imaging findings of pathologically proven eight porta hepatic schwannomas (mean age, 55 years; range, 38-80 years; one male and seven females). Preoperative imaging included three ultrasonography, eight CT, eight MRI, and two FDG-PET/CT. RESULTS: All patients were asymptomatic. The mean tumor size was 61.9 mm (range, 30-180 mm), and all tumors demonstrated well-defined lesions on ultrasonography and their solid components showed soft tissue attenuation on non-contrast CT. MRI showed two distinct components in all cases: the component with T1-weighted hypointensities and T2-weighted hyperintensities with poor enhancement (suggestive of Antoni B histology); the component with T2-weighted hypointensities with gradually increasing enhancement (suggestive of Antoni A histology), resulting in a heterogeneous pattern on post-contrast CT or MRI (8/8, 100%). The separated deviation of surrounding bile ducts and vessels without obstruction allowed the recognition of extrahepatic localization and their benign nature. A ginger root-like morphology (2/8, 25%) seemed to be suggestive of extension along the Glisson's sheath, although this finding was not seen frequently. CONCLUSION: Recognizing imaging features such as extrahepatic location, benign nature with internal structures suggestive of Antoni A/B histology, and characteristic tumor extension may provide key diagnostic clues for porta hepatic schwannomas.

Impact of Cytoreductive Nephrectomy Following Nivolumab Plus Ipilimumab Therapy for Patients With Advanced Renal Cell Carcinoma.

BACKGROUND/AIM: CheckMate 214 study revealed that nivolumab plus ipilimumab combination therapy showed a strong and durable effect compared to sunitinib for patients with advanced renal cell carcinoma (aRCC). Most of the patients underwent previous nephrectomy before systemic treatment. We retrospectively investigated the clinical outcomes of Japanese patients treated with cytoreductive nephrectomy following nivolumab plus ipilimumab for aRCC. PATIENTS AND METHODS: Seventy-nine patients were treated with systemic therapy for aRCC between October 2018 and August 2021 at the Saitama Medical University International Medical Center. Ten of 61 patients treated with nivolumab plus ipilimumab underwent cytoreductive nephrectomy after the combined immunotherapy. RESULTS: The median overall survival and progression-free survival were 24.3 and 15.9 months, respectively. The objective response rate was 50.8%; 9.8% of patients had a complete response, and the median time to objective response was 3.2 (range=1.3-19.7) months. The estimated percentage of patients who sustained an objective response at 30 months was 73.0%. Twenty-three patients (74%) in the complete or partial response (CR/PR) group, 11 patients (52%) in the stable disease (SD) group, and two patients (22%) in the progressive disease (PD) group had immune-related adverse events of grade 3 or higher, respectively. For all 10 patients, cytoreductive nephrectomy following nivolumab plus ipilimumab treatment were completed safely. Three patients achieved a pathological complete response without viable cancer cells. Only two patients had residual lesions on images after deferred cytoreductive nephrectomy; the remaining patients achieved radiological CR. CONCLUSION: Cytoreductive nephrectomy after nivolumab plus ipilimumab treatment could be useful in a limited number of cases, possibly resulting in curative nephrectomy due to the durable therapeutic effect of immunotherapy.

Utility of magnetic resonance imaging for differentiating malignant mesenchymal tumors of the uterus from T2-weighted hyperintense leiomyomas.

PURPOSE: To generate a new discrimination method to distinguish between malignant mesenchymal tumors of the uterus and T2-weighted hyperintense leiomyoma based on magnetic resonance imaging findings and clinical features. MATERIALS AND METHODS: Data from 32 tumors of 32 patients with malignant mesenchymal tumors of the uterus and from 34 tumors of 30 patients with T2-weighted hyperintense leiomyoma were analyzed. Clinical parameters, qualitative magnetic resonance imaging features, including computed diffusion-weighted imaging, and quantitative characteristics of magnetic resonance imaging of these two tumor types were compared. Predictive values for malignant mesenchymal tumors of the uterus were calculated using variant discriminant analysis. RESULTS: The T1 bright area on qualitative assessment and mean apparent diffusion coefficient value on quantitative assessment yielded the most independent magnetic resonance imaging differentiators of malignant mesenchymal tumors of the uterus and T2-weighted hyperintense leiomyoma. The classification accuracy of the variant discriminant analysis based on three selected findings, i.e., a T1 bright area, computed diffusion-weighted imaging with a b-value of 2000s/mm2 (cDWI2000), and T2-hypointense bands, was 84.8% (56/66), indicating high accuracy. CONCLUSIONS: Variant discriminant analysis using the T1 bright area, cDWI2000, and T2-hypointense bands yielded high accuracy for differentiating between malignant mesenchymal tumors of the uterus and T2-weighted hyperintense leiomyoma.

A Study of the Right Colonic Vascular Anatomy: Correlations between Veins and Arteries.

OBJECTIVES: Few studies have examined the correlations between the arteries and veins of the right colon. In this study, we aimed to use high-resolution CT scans to understand the vascular anatomy of Henle's gastrocolic trunk and review the terminology describing the arteries and veins of the right colon. METHODS: This retrospective study has examined patients who underwent laparoscopic colectomy for right colon cancer in a single institution in Japan. Scans from consecutive patients who underwent surgery between October 2017 and March 2020 (n = 165) were examined. Preoperative CT images were used to create multiplanar reformation images and volume rendering images. RESULTS: Among the 139 patients with Henle's gastrocolic trunk (GCT) present, arteries accompanying the accessory right colic vein (ARCV) were most common on the right branch of the middle colic artery (MCA) (71.2%), followed by the right colic artery (RCA) (19.4%); meanwhile, 9.4% of the patients had no accompanying arteries. Of patients with no accompanying arteries to the ARCV, RCA was present in 15.4%. Among the 26 patients with no GCT, the right colic vein (RCV) existed in 15 patients, with the artery accompanying the RCV most commonly being the right branch of the MCA (66.6%), followed by the RCA (33.3%). CONCLUSIONS: Irrespective of the presence of GCT, approximately 70% of the arteries accompanying the drainage vein from the right colon were the right branch of the MCA. We suggest that vascular branch formation be considered preoperatively in surgical management for right colon cancer.

Quantitative analysis of gadoxetic acid-enhanced MRI for the differential diagnosis of focal liver lesions: Comparison between estimated intralesional gadoxetic acid retention by T1 mapping and conventional processing methods.

PURPOSE: To compare the estimated quantity of intratumor gadoxetic acid retention using T1 mapping of gadoxetic acid-enhanced magnetic resonance imaging (MRI) versus conventional processing methods for the differential diagnosis of focal liver lesions. METHODS: Seventy patients with hepatic lesions (colorectal metastasis (CRM) [n = 28], hepatocellular carcinoma (HCC) [n = 20], hemangioma [n = 12], and intrahepatic cholangiocarcinoma (ICC) [n = 10]) underwent gadoxetic acid-enhanced MRI, including pre- and post-contrast T1-weighted imaging and T1 mapping. Quantitative analyses included the lesion-to-liver signal intensity ratio (SIR) on hepatobiliary phase images, the pre- and post-contrast lesion T1 value difference (ΔT1 [ms]), and the lesion retention index (LRI [%]), which was the estimated intralesional gadoxetic acid retention calculated on pre- and post-contrast T1 maps using a two-compartment pharmacokinetic model. Results were compared between the four subcategories of focal liver lesions using the Kruskal-Wallis test, followed by the post-hoc Dunn's test and receiver operating characteristic (ROC) analysis to distinguish between pairs of the four lesion subcategories. RESULTS: This study identified significant differences in the LRI of the four lesion subcategories (p <  0.01), without significant differences in ΔT1 or SIR. Post-hoc analysis demonstrated significant differences in CRM vs. hemangioma (p <  0.01), hemangioma vs. ICC (p <  0.01), and HCC vs. ICC (p =  0.047) for the LRI. CONCLUSIONS: The quantity of intratumor gadoxetic acid retention estimated using pre- and post- contrast T1 mapping could distinguish focal liver lesions, unlike conventional processing methods, and captured unique lesion characteristics.

The inferior mesenteric artery arising from the superior mesenteric artery demonstrated with 3D-CT: A case report.

The inferior mesenteric artery arising from the superior mesenteric artery is an extremely rare anatomic variation. We report a case with this variation demonstrated with 3-dimensional contrast-enhanced computed tomography, which later was confirmed at surgery. The ordinary inferior mesenteric artery arising from the aorta was absent. Previously reported cases with this variation are reviewed. 3-dimensional contrast-enhanced computed tomography is useful for in vivo visualization of aberrant arterial anatomy.

Meningeal carcinomatosis from bladder cancer: A case report and review of the literature.

A 66-year-old Japanese male patient was referred to Saitama Medical University International Medical Center for treatment of bladder cancer (clinical stage T2 or higher without metastasis), and underwent radical cystectomy with pelvic lymphadenectomy. The histopathological diagnosis was high-grade urothelial carcinoma (pathological stage T2bN2, ly1, v0) and 2 cycles of adjuvant systemic chemotherapy (gemcitabine plus cisplatin) were administered. At 15 months after the operation, mediastinal and lung hilar lymph nodes and multiple bone metastases were identified on computed tomography imaging. After 3 cycles of the previous regimen as salvage systemic chemotherapy, the lymph node metastases had shrunk and the bone metastases were stable; therefore, further chemotherapy was planned. At 26 days after the initiation of the 4th cycle, the patient felt nausea and lower limb weakness. Spinal and brain magnetic resonance imaging with contrast medium revealed diffuse enhancement at the surface of the spinal cord and brain. In addition, abnormal signal intensity in the subarachnoid space was observed on fluid-attenuated inversion recovery imaging; therefore, the patient was diagnosed with meningeal carcinomatosis (MC). Treatment, including whole-brain radiotherapy, was planned for MC; however, the patient's condition rapidly worsened and he succumbed to the disease 14 days after the diagnosis of MC. The definitive diagnosis of MC was confirmed at autopsy.

A Case of Renal Oncocytoma with Renal Venous Tumor Thrombus.

Renal oncocytoma is generally regarded as a benign renal tumor. We herein report a case of large renal oncocytoma with renal venous tumor thrombus. The patient may need to be carefully followed up because hematogenous metastasis may occur.

Acute life-threatening portal venous dilatation induced by a huge solitary fibrous tumor of the omentum.

An 85-year-old woman was referred to the medical oncology department because of a hypogastric mass. Contrast-enhanced CT showed a large hypervascular mass in the lower abdomen. CT angiography with volume rendering imaging revealed a vascular pedicle with an arborizing pattern of vessels. Many thick, early draining veins shunting into the portal vein were detected. Before surgery, the maximum size of the portal vein was 22 mm in diameter. Laparotomy revealed a huge, encapsulated, well-defined, hard tumor with hypervascularization, which was appended to the omentum. The mass with the omentum was curatively resected; it was 19 cm x 17 cm x 13 cm in size and 1915 g in weight. Histological features were consistent with a benign solitary fibrous tumor of the omentum, despite the tumor size and necrotic area found in the specimen. q Ultrasonography and CT performed at a 28-month follow-up revealed no evidence of tumor recurrence. Venous dilatation including that of the portal veins had diminished.

Variations in the origin of the vertebral artery and its level of entry into the transverse foramen diagnosed by CT angiography.

INTRODUCTION: The origin of the vertebral artery (VA) varies, though most VAs enter the transverse foramen (TF) of the sixth cervical vertebra. On computed tomography (CT) angiographic images, we evaluated the prevalence of variations of both VA origin and its level of entry into the TF. METHODS: We retrospectively reviewed CT angiographic images of 2,287 patients obtained using either of two 64-slice multidetector CT scanners. All patients were Japanese and underwent scanning from the aortic arch to the intracranial region; most had or were suspected of having cerebrovascular diseases. RESULTS: The left VA (LVA) arose from the aorta between the left common carotid artery and left subclavian artery in 94 patients (4.1 %) and in other variations in 44 patients (1.9 %). The right VA (RVA) arose from the extreme proximal segment of the right subclavian artery in 72 patients (3.1 %) and in other variations in 14 patients (0.6 %). The LVA entered the sixth TF in 2,127 patients (93.0 %), and the RVA entered the sixth TF in 2,146 patients (93.8 %). Anomalous origin and anomalous entry level into the TF correlated strongly. CONCLUSIONS: The total prevalence of variation in the origin of the LVA was 6.0 % and of the RVA, 3.8 %. The total prevalence of variation in entry level into the TF was 7.0 % for the LVA and 6.2 % for the RVA. Recognition and reporting of these variations is important in interpreting CT angiography to prevent complications during surgery of the aortic arch or lower neck.

Vertebral artery variations at the C1-2 level diagnosed by magnetic resonance angiography.

INTRODUCTION: The craniovertebral junction is clinically important. The vertebral artery (VA) in its several variations runs within this area. We report the prevalence of these VA variations on magnetic resonance angiography (MRA). METHODS: We retrospectively reviewed MRA images, obtained using two 1.5-T imagers, of 2,739 patients, and paid special attention to the course and branching of the VA at the level of the C1-2 vertebral bodies. RESULTS: There were three types of VA variation at the C1-2 level: (1) persistent first intersegmental artery (FIA), (2) VA fenestration, and (3) posterior inferior cerebellar artery (PICA) originating from the C1/2 level. The overall prevalence of these three variations was 5.0%. There was no laterality in frequency, but we found female predominance (P < 0.05). We most frequently observed the persistent FIA (3.2%), which was sometimes bilateral. We found VA fenestration (0.9%) and PICA of C1/2 origin (1.1%) with almost equal frequency. Two PICAs of C1/2 origin had no normal VA branch. CONCLUSIONS: We frequently observed VA variations at the C1-2 level and with female predominance. The persistent FIA was most prevalent and sometimes seen bilaterally. Preoperative identification of these variations in VA is necessary to avoid complications during surgery at the craniovertebral junction.

[Uterine artery embolization for leiomyoma: complications and effects on fertility].

Uterine artery embolization (UAE) for leiomyoma is becoming accepted as an alternative to surgical treatment. However, gynecologists who have treated follow-up patients are greatly concerned about the postoperative course after UAE. One significant complication after UAE is infection owing to obstruction resulting from the sloughing of necrotic fibroids that interfere with the passage of intrauterine discharge. In our UAE procedures, the incidence of infection requiring hospitalization was 3.6%, and one patient (0.22%) had to undergo hysterectomy. Transcervical resection (TCR) using hysteroscopy is an extremely effective surgical intervention for removing necrotic fibroids for reserve of the uterus. However, additional treatment for intrauterine abnormalities after UAE may rest on whether or not the hysteroscopic procedure was performed. Although ovarian function after UAE seems to be maintained in patients < or = 44 years of age, serious complications include intrauterine adhesions that appear as amenorrhea or hypomenorrhea and lead to infertility. The results of our hysteroscopic evaluation after UAE in 7 patients who wished to conceive was intrauterine adhesion in four patients, subendometrial liner scar in one patient, and yellowing of the endometrium in three patients. However, in spite of impairment of the endometrium, the pregnancy rate after UAE in our study was 5/10(50.0%). It is essential that the indications of UAE for patients who wish to conceive be decided according to careful individual evaluation, and cautious follow-up is necessary.

Differentiation between hemangiomas and cysts of the liver with single-shot fast-spin echo image using short and long TE.

PURPOSE: This study was designed to examine whether hepatic hemangioma can be differentiated from cyst by use of single-shot fast spin echo (SSFSE) sequence without contrast material. METHODS: SSFSE images with a short TE (90 msec) and a long TE (600-700 msec) were obtained in 30 patients with cyst (n= 19) or hemangioma (n= 26) on a 1.5-T unit. In short TE, both cysts and hemangiomas showed well-defined hyperintense masses. RESULTS: In long TE, however, cysts showed well-defined hyperintense masses, whereas hemangiomas were poorly defined faint masses with intermediate signal intensity. The contrast-to-noise ratio of hemangiomas and cysts were 3.23 and 52.9 (p < 0.001) in long TE; there was no overlap for the ranges, and the result did not depend on lesion size. All 45 lesions were differentiated correctly with these qualitative criteria. CONCLUSIONS: SSFSE with short and long TE is useful in the evaluation of cyst and hemangioma of the liver.