Efficacy of uterine artery embolization (UAE) for uterine fibroids according to FIGO classification: a single-center experience.

OBJECTIVE: This study aims to retrospectively evaluate the outcomes of uterine artery embolization (UAE) for uterine fibroids (UFs), specifically submucosal UFs, according to the International Federation of Gynecology and Obstetrics (FIGO) classification of UFs. MATERIALS AND METHODS: Forty-two patients with symptomatic UFs underwent UAE with Embosphere® between July 2016 and November 2021. MRI was performed before, at 3 and 6 months after the UAE. At each examination, the volume of UF was measured, and the percentage volume reduction rate (VRR) was calculated. The technical success rate (TSR), symptom improvement rate (SIR), regrowth rate (RR) after 6 months, and adverse events (AEs) were examined; VRR was compared between patients with submucosal UFs (FIGO types 0-2, group A), those with submucosal contacts (FIGO type 3, group B), and those without submucosal UFs (FIGO types 4-7, group C). Statistical analysis was performed on the difference in VRR between groups A, B, and C at 3 and 6 months after UAE. The relationship with hormone levels before UAE and VRR was evaluated. RESULTS: Thirty-seven of the 42 patients were evaluated. Overall, VRR was 37.0% at 3 months and 52.1% at 6 months; TSR, SIR, and RR were 100%, 95.2%, and 5.4%, respectively; VRR at 6 months was 80.7% for group A (n = 7), 57.8% for group B (n = 13), and 37.1% for group C (n = 17). Significant differences were found between A and C (p < 0.001) and B and C (p = 0.023). Hormone levels before UAE had no effect on VRR. There was no significant AEs other than grade 3 pulmonary embolism in one patient. CONCLUSION: UAE was effective for submucosal FIGO types 0-3. UAE was especially useful as an option for FIGO type 3 with a low protrusion rate that is difficult to treat with transcervical resection.

Successful management of thrombocytopenia by partial splenic embolization in patients with advanced gastric cancer and invasion of the splenic vein: Case reports.

RATIONALE: Hypersplenism causes thrombocytopenia, which may lead to the reduction or discontinuation of chemotherapy. Partial splenic embolization (PSE) is an effective treatment for thrombocytopenia associated with hypersplenism. However, there have been no reports of patients with gastric cancer who have resumed and continued chemotherapy after PSE for splenic hypersplenism associated with tumor infiltration.Here, we report two cases in which we performed PSE for hypersplenism associated with gastric cancer that had invaded the splenic vein. Chemotherapy was continued in both cases. PATIENT CONCERNS: Both patients developed thrombocytopenia with splenomegaly due to advanced gastric cancer that required discontinuation of chemotherapy. DIAGNOSIS: Upper gastrointestinal endoscopy and computed tomography showed advanced gastric cancer with invasion of the splenic vein and splenomegaly. Both patients developed thrombocytopenia. INTERVENTIONS: Patients were treated with PSE. OUTCOMES: PSE produced an increase in thrombocyte count, and chemotherapy could be resumed. LESSONS: PSE seems to be a useful treatment for thrombocytopenia with splenomegaly associated with advanced gastric cancer and may allow continuation of chemotherapy.

Transcirculation microballoon-assisted coil embolization for dorsal pancreatic artery aneurysm due to celiac artery dissection: A case report.

The dorsal pancreatic artery is a part of peripancreatic arcade connecting celiac artery to transpancreatic artery. A dorsal pancreatic artery aneurysm derived from dissection of celiac artery is a rare pathology, and it sometimes requires ingenious strategy in an endovascular surgery. Hereby, we report a case of a patient who underwent coil embolization for dorsal pancreatic artery aneurysm due to celiac artery dissection by applying transcirculation approach of a balloon catheter through the peripancreatic arcade, which was successfully achieved.

Successful Treatment of Bronchial Artery Aneurysms Associated With Racemose Hemangioma by Combined Therapy of Transcatheter Bronchial Artery Embolization and Thoracic Endovascular Aortic Repair.

A 70-year-old man was referred to our hospital for an abnormal chest shadow. Enhanced computed tomography (CT) revealed 2-humped bronchial artery aneurysms (BAAs) associated with racemose hemangioma. The combined therapy of transcatheter bronchial artery embolization and thoracic endovascular aortic repair was performed. Postoperative CT confirmed the complete exclusion of the aneurysms with no evidence of an endoleak. Our result suggests that this combined therapy is a safe and effective treatment for BAA.

Long-term Histopathologic Follow-up of a Spherical Embolic Agent; Observation of the Transvascular Migration of HepaSphereTM.

Very few studies have been published on the long-term histopathologic follow-up of spherical embolic agents after their injection. To our knowledge, there are no reports in the literature regarding pathological analysis of the transvascular migration of HepaSphere particles. We here report a case of a patient with hepatocellular carcinoma (HCC) who underwent liver transplantation 12 months after drug eluting microsphere transcatheter arterial chemoembolization (DEM-TACE), and long-term histopathologic follow-up of the microspheres was performed. Furthermore, to our knowledge, this is the first report in which transvascular migration of a HepaSphere particle was confirmed histologically. A 60-year-old male with chronic hepatitis B was treated with entecavir and seroconversion was obtained. The patient had decompensated cirrhosis, and desired to undergo living donor liver transplantation (LDLT). However, 2 HCC tumors of 3 cm or less were detected in his liver. The transplantation surgeon proposed DEM-TACE as a bridge therapy. The HCCs were located in the right lobe and lateral segment of the liver. A 1.9 F preshaped microcatheter (ProgreatΣ, Terumo, Japan) was selectively inserted into the A3 and anterior segmental branch, 10 mg of epirubicin was injected into each artery, and the arteries were embolized with 7 mg and 13 mg of HepaSphere loaded with epirubicin, respectively. Two months later, contrast-enhanced CT displayed a complete response. At that time, lung metastasis was suspected, but after partial lung resection, the patient was diagnosed as having inflammatory granuloma. One year after DEM-TACE treatment, LDLT was performed. No cancerous cells were detected in the area where the tumor was present, but 22 HepaSphere particles were detected. All particles were present in the interstitium. Furthermore, the transvascular migration of a HepaSphere particle was histologically confirmed. The largest and smallest HepaSphere diameters were 241.6 ± 52.5 µm and 186.5 ± 41.4 µm, respectively, and deformity was 22.6% ± 13.0 %. All the HepaSpheres detected in the examined pathological specimen were noted to be extravascular.

Successful recanalization of acute extensive portal vein thrombosis by aspiration thrombectomy and thrombolysis via an operatively placed mesenteric catheter: a case report.

Portal vein thrombosis (PVT) after hepatobiliary surgery is rare but can cause lethal and severe complications. If early diagnosis and recanalization can be achieved, the PVT is expected to be eliminated. A 70-year-old male was diagnosed as having hepatocellular carcinoma occupying the right lobe of the liver. As oligometastatic lung tumors were simultaneously detected on contrast-enhanced CT (CECT), hepatectomy was not indicated. However, the primary tumor was very large, and as large tumor size can be associated with an unfavorable prognosis, and owing to the strong desire of the patient, he underwent right lobe hepatectomy. Jaundice appeared on post-operative Day (POD) 2 and CECT displayed slight intraheptatic bile duct dilation. However, a PVT did not exist at this time. Percutaneous transhepatic biliary drainage was performed and Doppler echo displayed intrahepatic and extrahepatic PVT on post-operative Day 5. Emergent thrombectomy was performed using a Vasplyser PlusTM thrombus aspiration catheter (Johnson & Johnson K.K. Medical Company, Tokyo, Japan) via the ileocolic vein under laparotomy. The mesenteric catheter was placed at the distal point of the residual PVT. Thrombolysis and anticoagulant therapy were performed using heparin and urokinase. In the CECT performed 16 days after the additional operation, the PVT had disappeared and the portal vein was completely recanalized. The mesenteric catheter was removed on the same day and oral anticoagulant therapy was continued. At the time of writing, 14 months have passed with no recurrence of PVT. Early diagnosis of PVT enables treatment with emergent thrombectomy, thrombolysis, and anticoagulant therapy. These treatments result in the improvement of portal vein flow and the complete disappearance of PVT.

Salvage Embolization and Histologic Analysis of Gastric Cancer with Hemorrhagic Shock Using Spherical Embolic Material.

BACKGROUND: In a recent study, it was reported that transcatheter arterial embolization with spherical embolic material for life-threatening hemorrhages in various cancer patients was safe and effective. Calibrated microspheres are able to access distal regions of the target arteries, which results in the disappearance of tumor staining. However, there are few reports on the pathological behavior of EmboSpheres in gastric cancer specimens. In this case, we succeeded in salvage embolization for advanced gastric cancer with hemorrhagic shock using spherical embolic material. To our knowledge, this is the first report of a pathological evaluation of spherical embolic microspheres in a gastric cancer specimen. CASE REPORT: A 70-year-old man with scirrhous gastric cancer was admitted to our hospital for staging laparoscopy. Unfortunately, he had a sudden onset of hematemesis and melena leading to hemorrhagic shock due to bleeding from the gastric cancer. While undergoing a rapid blood transfusion, he underwent emergent embolization to achieve hemostasis. The left gastric and right gastroepiploic arteries were embolized with spherical embolic material, and the patient survived. Two days later, the patient was able to undergo gastrectomy. A large number of microspheres were observed in areas of hemorrhage. The range and median diameter of the minor axis were 177-1048 µm and 281 µm, respectively. CONCLUSIONS: Transcatheter arterial embolization using spherical embolic material could become one of safe and effective options, especially when there is no extravasation or pseudoaneurysm but only tumor staining from the clinical and pathological point of view.

Coil embolization for pulmonary artery injury caused by chest tube drainage.

Pulmonary artery injury caused by chest tube drainage is rare, but it requires prompt diagnosis to perform urgent surgical repair. We report that a 53-year-old man who suffered from pulmonary artery injury by chest tube drainage was successfully treated by coil embolization.

Distinguishing liver haemangiomas from metastatic tumours using gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced diffusion-weighted imaging at 1.5T MRI.

INTRODUCTION: The aim of this study to evaluate the effectiveness of enhanced diffusion-weighted imaging (DWI) for distinguishing liver haemangiomas from metastatic tumours (mets). METHODS: This study included 23 patients with 27 haemangiomas and 26 patients with 46 mets. Breath-holding diffusion-weighted imaging (DWI) (b-values of 0, 50, 100, 150, 200, 400 and 800 s/mm2 ) were obtained before and 20 min after injection of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA). Lesion contrast-to-noise ratios (CNRs) were calculated. The data were processed using the bi-exponential model of intravoxel incoherent motion (IVIM). Receiver operating characteristic analysis was performed to compare the diagnostic performance when distinguishing haemangioma from mets. RESULTS: The CNRs of haemangioma and mets at post-contrast enhancement increased. All IVIM parameters for liver haemangioma and mets showed no significant differences between pre- and post-contrast enhancement. The highest Az value of CNR and IVIM parameters occurred at a post-contrast b-value of 0 s/mm2 and true diffusion (D). The highest qualitative evaluation occurred at a b-value of 800 s/mm2 . The sensitivity and specificity, with a CNR of 100 or higher at a post-contrast b-value of 0 s/mm2 and considered to be haemangioma, were 89% and 67% (<10 mm, 91%, 77%) respectively. The sensitivity and specificity, when D was higher than 1.4 × 10-3 mm2 /s, were 74% and 83% (<10 mm, 64%, 77%) respectively. The sensitivity and specificity of qualitative evaluation by enhanced DWI were 74% and 76% (<10 mm, 64%, 80%) respectively. CONCLUSIONS: The accuracy of the CNR was highest with b = 0; however, examination at high b-values had advantages in the qualitative evaluation of some small-size lesions.

Is diffusion-weighted imaging a significant indicator of the development of vascularization in hypovascular hepatocellular lesions?

OBJECTIVE: The objective was to evaluate the efficacy of diffusion-weighted imaging (DWI) in predicting the development of vascularization in hypovascular hepatocellular lesions (HHLs). MATERIALS AND METHODS: Forty-two HHLs that were diagnosed by computed tomographic (CT) arteriography were evaluated retrospectively. The lesion on DWI was classified as isointense, hypointense, or hyperintense. Follow-up studies that included intravenous dynamic CT or magnetic resonance imaging were performed. RESULTS: The 730-day cumulative developments of vascularization in hypointense, isointense, and hyperintense lesions were 17%, 30%, and 40%, respectively. The differences among these developments were not statistically significant. CONCLUSION: The signal intensity on DWI showed no significant difference in the development of vascularization.

Hemodynamic changes during balloon-occluded transarterial chemoembolization (B-TACE) of hepatocellular carcinoma observed by contrast-enhanced ultrasound.

Balloon-occluded transarterial chemoembolization (B-TACE) is able to achieve denser accumulation of Lipiodol emulsion (LE) in hepatocellular carcinoma (HCC) than conventional TACE. However, to maximize the therapeutic effect of B-TACE, it is imperative to understand the hemodynamic changes that occur during arterial occlusion. We here present two patients with HCC in whom the hemodynamic changes during arterial occlusion were depicted and evaluated by contrast-enhanced ultrasound (CEUS). Arterial flow beyond the catheter tip was observed by CEUS even after balloon occlusion. In one patient, a reduction in arterial blood flow in the HCC was observed by CEUS during balloon occlusion of the target area for embolization. After B-TACE, dense LE accumulation in the HCC nodule was confirmed by flat-panel detector CT, indicating an excellent therapeutic effect. In the other patient, no changes in arterial blood flow in the HCC nodule were observed by CEUS during balloon occlusion of the target area for embolization. After B-TACE, intermediate LE accumulation in the HCC nodule was confirmed by flat-panel detector CT, indicating an incomplete therapeutic effect. The findings obtained in the two patients presented here suggest that B-TACE can be performed more effectively and reliably by monitoring blood flow using CEUS.

Recanalization of iatrogenic dissection of the superior mesenteric artery: a case report.

We present a case of acute abdominal pain due to a long-segment iatrogenic superior mesenteric artery dissection, which was immediately treated successfully with balloon fenestration of the intimal flap, resulting in complete resolution of the symptoms without recurrence during the 2-year follow-up period.

Distinguishing hepatic hemangiomas from metastatic tumors using T1 mapping on gadoxetic-acid-enhanced MRI.

OBJECTIVE: The objective was to evaluate the usefulness of T1 mapping in distinguishing hepatic hemangiomas from metastatic tumors on gadoxetic-acid-enhanced magnetic resonance imaging. METHODS: We examined 20 hemangiomas in 14 patients and 21 metastatic tumors in 11 patients. We performed T1 mapping using the double-flip angle method before and after the injection of gadoxetic acid. Quantitative evaluation was carried out using the pre- and post-contrast enhancement ratios (CERs), and qualitative evaluation was conducted to evaluate the added value of T1 mapping using receiver operating characteristics analysis. RESULTS: The mean CERs of metastatic tumors at 70 s, 240 s and 20 min after the injection of gadoxetic acid were 1.54 (95% confidence interval: 1.37-1.71), 1.47 (1.34-1.6) and 1.30 (1.19-1.41); those of hemangiomas were 3.36 (2.41-4.31), 3.06 (2.44-3.68) and 2.20 (2.02-2.38), respectively. The mean CERs of hemangiomas were significantly higher than those of metastatic tumors (P<.05). When the mean CER cutoff value 20 min after the injection was set at 1.6, the diagnostic sensitivity of hepatic hemangiomas was 100%. There was no added value observed statistically in the qualitative evaluation of T1 mapping (P>.05). CONCLUSION: It is valuable to evaluate quantitatively T1 mapping 20 min after hepatobiliary phase acquisition in the case of difficulty in distinguishing hepatic hemangiomas from metastatic tumors qualitatively.

MR characterization of focal nodular hyperplasia: gadoxetic acid versus superparamagnetic iron oxide imaging.

PURPOSE: We evaluated the diagnostic efficacy of gadoxetic acid- and superparamagnetic iron oxide (SPIO)-enhanced magnetic resonance (MR) imaging for focal nodular hyperplasia (FNH). MATERIALS AND METHODS: We retrospectively evaluated 11 patients with 11 FNHs. Both gadoxetic acid- and SPIO-enhanced MR imaging were performed. A 3-dimensional (3D) volumetric interpolated breath-hold examination was used with the gadoxetic acid dynamic study. SPIO-enhanced MR imaging included T2- and T2*-weighted images. We quantitatively and qualitatively compared lesion-specific enhancement of both contrast media. RESULTS: The mean signal-to-noise (S/N) ratio of the FNH lesions differed significantly on pre- and postenhanced imaging of each contrast medium (P<0.05); mean contrast-to-noise (C/N) ratio did not (P>0.05). All observers described all lesions as hyperintense in the arterial phase on gadoxetic acid-enhanced MR imaging and observed the presence of central scar, fibrous septa, and rim most clearly in gadoxetic acid-enhanced hepatobiliary phase images. CONCLUSION: Gadoxetic acid-enhanced MR imaging was more useful than SPIO-enhanced MR imaging in characterizing FNH.

Histological grade of differentiation of hepatocellular carcinoma: comparison of the efficacy of diffusion-weighted MRI with T2-weighted imaging and angiography-assisted CT.

INTRODUCTION: The purpose of this study is to determine the usefulness of diffusion-weighted imaging (DWI) for evaluating the histological grade of differentiation of hepatocellular carcinoma (HCC) compared with T2-weighted imaging (T2WI) and tumour haemodynamics. METHODS: We retrospectively evaluated 32 patients with 42 pathologically confirmed HCC nodules. These patients underwent MRI, CT during arterial portography and CT hepatic arteriography. We evaluated the relationship between the histological grade of differentiation and the apparent diffusion coefficient (ADC) values, conspicuity of tumour on DWI, DWI and T2WI contrast-to-noise (C/N) ratios and tumour haemodynamics. RESULTS: There was no correlation between the histological grade of differentiation and the ADC values. The DWI C/N ratio was significantly different among all histological grades, but the T2WI C/N ratio was not. Tumour conspicuity on DWI correlated well with the histological grade of differentiation, but tumour haemodynamics only partially correlated with the histological grade of differentiation. CONCLUSION: DWI was useful for evaluating the histological grade of differentiation of HCC.

Comparison of Kupffer-phase Sonazoid-enhanced sonography and hepatobiliary-phase gadoxetic acid-enhanced magnetic resonance imaging of hepatocellular carcinoma and correlation with histologic grading.

OBJECTIVES: To determine the relative wash-out of hepatocellular carcinomas and dysplastic nodules using Kupffer-phase sonography with Sonazoid (Daiichi-Sankyo, Tokyo, Japan) enhancement and hepatobiliary-phase gadoxetic acid-enhanced magnetic resonance imaging (MRI) in the evaluation of the histopathologic grades of individual nodules. METHODS: This retrospective study included 66 consecutive patients with 78 histologically confirmed hepatocellular carcinomas and dysplastic nodules. In patients with carcinomas, 33 were well differentiated; 29 were moderately differentiated; and 11 were poorly differentiated; and there were 5 dysplastic nodules. All patients underwent both gadoxetic acid-enhanced MRI and Sonazoid-enhanced sonography. The interval between the two imaging examinations was less than 30 days. Six radiologists independently reviewed both images and rated the degree of relative wash-out between the tumorous and nontumorous areas on Kupffer- and hepatobiliary-phase images using a continuous rating scale. We compared these results with the histopathologic grade of each nodule, and the results were then analyzed with multireader multicase receiver operating characteristic analysis. RESULTS: The average Kupffer-phase (P < .001) and hepatobiliary-phase (P = .004) rating scores increased as the carcinomas became less differentiated (Kruskal-Wallis test). The diagnostic accuracies of the average area under the receiver operating characteristic curve, which were estimated using the confidence levels of the relative wash-out of the Kupffer- and hepatobiliary-phase images, were 0.705 and 0.785 for dysplastic nodules versus well-, moderately, and poorly differentiated carcinomas (P = .517), 0.791 and 0.687 for dysplastic nodules and well-differentiated carcinomas versus moderately and poorly differentiated carcinomas (P = .093), and 0.871 and 0.716 for dysplastic nodules and well-and moderately differentiated carcinomas versus poorly differentiated carcinomas (P = .005), respectively. CONCLUSIONS: Kupffer-phase Sonazoid-enhanced sonography and hepatobiliary-phase gadoxetic acid-enhanced MRI may be useful in estimating the histologic grade, although Kupffer-phase Sonazoid-enhanced sonography may be more accurate in distinguishing hepatocellular carcinomas, especially moderately and poorly differentiated types.

Assessment of arterial hypervascularity of hepatocellular carcinoma: comparison of contrast-enhanced US and gadoxetate disodium-enhanced MR imaging.

OBJECTIVE: To compare contrast-enhanced (CE) ultrasound with gadoxetate disodium-enhanced magnetic resonance (MR) imaging in the assessment of arterial hypervascularity of hepatocellular carcinoma (HCC) and dysplastic nodule (DN), with CT during hepatic arteriography (CTHA) as the reference standard. METHODS: This study included 54 consecutively diagnosed patients, with 57 histologically confirmed HCCs and 3 DNs (high-grade). All patients underwent CE ultrasound, gadoxetate disodium-enhanced MR imaging and CTHA. Two trained diagnostic radiologists interpreted the CTHA images and rated the degree of intratumoral arterial vascularity by consensus using a five-point confidence scale as the reference standard. In the observer study, the degrees of vascularity on CE ultrasound and gadoxetate disodium-enhanced MR images were qualitatively analysed by four independent readers using a five-point confidence scale. Diagnostic accuracy was analysed by receiver-operating characteristic (ROC) analysis. RESULTS: The diagnostic accuracies of the average area under the ROC curve (AUC) were significantly greater with CE ultrasound (average AUC: 0.94; 95% confidence interval [CI]: 0.88-1.00) than with gadoxetate disodium-enhanced MR imaging (average AUC 0.84, 95% CI 0.74-0.93, P = 0.0014). CONCLUSION: Contrast-enhanced ultrasound yields a significantly higher AUC value than gadoxetate disodium-enhanced MR imaging in the assessment of arterial hypervascularity of HCC and DN. KEY POINTS: • Arterial hypervascularity is an important feature determining treatment options in hepatocellular carcinoma. • It can be assessed by contrast-enhanced (CE) ultrasound or magnetic resonance (MR) imaging. • CE ultrasound was more accurate than Gd-EOB-DTPA MRI in assessing intratumoral vascularity. • Hypovascular hepatic nodules should be further investigated using CE ultrasound.

Diagnostic efficacy of gadoxetic acid-enhanced MRI for hepatocellular carcinoma and dysplastic nodule.

AIM: To evaluate the relationship between the signal intensity of hepatobiliary phase images on gadoxetic acid-enhanced magnetic resonance imaging (MRI) and histological grade. METHODS: Fifty-nine patients with 82 hepatocellular lesions were evaluated retrospectively. Hepatobiliary phase images on gadoxetic acid-enhanced MRI were classified into 3 groups: low, iso or high. Angiography-assisted computed tomography (CT) findings were also classified into 3 groups: CT during arterial portography, and CT hepatic arteriography: A: iso, iso or low; B: slightly low, iso or low; and C: low, high. We correlated angiography-assisted CT, hepatobiliary phase findings during gadoxetic acid-enhanced MRI and histological grades. Furthermore, correlations between MRI findings and histological grade for each hemodynamic pattern were performed. Correlations among radiological and pathological findings were statistically evaluated using the chi-square test and Fisher' s exact test. RESULTS: There was a significant correlation between histological grade and hemodynamic pattern (P < 0.05). There was a significant correlation between histological grade and signal intensity in the hepatobiliary phase (P < 0.05) in group A lesions. There was no significant correlation between histological grade and signal intensity in the hepatobiliary phase in group B or C lesions (P > 0.05). CONCLUSION: Signal intensity in the hepatobiliary phase correlated with histological grade in the lesions that maintained portal blood flow, but did not correlate in lesions that showed decreased or defective portal blood flow.