Severe veno-occlusive disease/sinusoidal obstruction syndrome after deceased-donor and living-donor liver transplantation.

Veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) occurring after liver transplantation is a relatively rare complication but it often takes a life-threatening course. However, the detailed etiology and mechanism of VOD/SOS after liver transplantation (LT) remains unclear. We report two cases with rapidly progressive VOD/SOS after ABO-identical LT resistant to various therapies. In case 1, in which the patient underwent deceased-donor LT, the first episode of acute allograft rejection was triggered VOD/SOS, and the presence of donor non-specific anti-HLA antibodies was confirmed. The recipient died with graft failure on day 46 after transplantation. Case 2, in which the patient underwent living-donor LT from the mother, had neither rejection nor mechanical venous obstruction, but condition of the patient rapidly worsened and he died on day 13 after transplantation. This recipient's direct cross-match test for the donor's B lymphocyte was strongly positive, but that for T lymphocyte was negative. In both cases, neither stenosis of hepatic vein outflow tract nor C4d deposition in post-transplantation liver biopsy specimens and autopsy specimen was found. On the other hand, in both cases, the patient was transfusion unresponsive thrombocytopenia and hyperbilirubinemia persisted postoperatively, and glycoprotein Ⅰ bα was strongly stained in the neighboring centrilobular area (zone 3), especially in the space of Disse, and platelet phagocytosis was observed in Kupffer cells and hepatocytes around zone 3 such as clinical xenotransplantation of the liver in post-transplantation liver biopsy specimens. From the viewpoint of graft injury, VOD/SOS was considered that sustained sinusoidal endothelial cells injury resulted in bleeding in the space of Disse and led to around centrilobular hemorrhagic necrosis, and the fundamental cause was damage around centrilobular area including sinusoid by acute cellular rejection, antibody-mediated rejection or ischemic reperfusion injury. The extrasinusoidal platelet activation, aggregation, and phagocytosis of platelets were some of the main reasons for VOD/SOS and transfusion-resistant thrombocytopenia.

Effect of hepatic arterial infusion chemotherapy of 5-fluorouracil and cisplatin for advanced hepatocellular carcinoma in the Nationwide Survey of Primary Liver Cancer in Japan.

BACKGROUND: The efficacy of hepatic arterial infusion chemotherapy for the treatment of advanced hepatocellular carcinoma (HCC) remains unclear. METHODS: The outcome of 476 patients with HCC who underwent hepatic arterial infusion chemotherapy with 5-fluorouracil and cisplatin (HAIC) were compared with 1466 patients who did not receive active therapy. RESULTS: A survival benefit of the therapy after adjusting for known risk factors was observed (hazard ratio, 0.48; 95% CI, 0.41-0.56; P<0.0001). In propensity score-matched analysis (n=682), median survival time was longer for patients who underwent chemotherapy (14.0 months) than for patients who did not receive active treatment (5.2 months, P<0.0001). CONCLUSION: For advanced HCC, HAIC is considered to be an effective treatment.

SU-D-217BCD-02: Online Angular Tube Current Modulation in X-Ray Computed Tomography: Can Tube Current Be Modulated Appropriately?

PURPOSE: In X-ray computed tomography (CT), X-rays are significantly less attenuated in the anteroposterior direction and more in the lateral direction. Therefore, the tube current should be adjusted within one gantry rotation using angular tube current modulation (TCM). The aim of this study was to evaluate whether online angular TCM could reduce radiation dose appropriately. METHODS: A 128-detector dual-source CT (SOMATOM Definition Flash; Siemens Healthcare, Erlangen, Germany) and an online TCM system (CARE Dose 4D; Siemens Healthcare) were used. Dose profiles were acquired using the CT Dose Profiler (RTI Electronics, Molndal, Sweden) and an elliptical cylindrical phantom (MHT; Kyoto Kagaku, Kyoto, Japan) for helical CT scans with and without TCM. In addition, absorbed dose distributions within a single section were acquired using an anthropomorphic phantom (RANI 10; The Phantom Laboratory, Salem, NY) and radiophotoluminescent glass dosimeters (RPLDs) (GD- 302M; Chiyoda Technol, Tokyo, Japan) for helical CT scans with and without TCM after placing RPLDs within all holes of one section and pasting them around the section. A graph of each absorbed dose distribution was drawn using graphing software (ORIGIN 8.6; OriginLab, Northampton, MA). RESULTS: The acquired dose profiles suggested that online angular TCM could adjust the tube current in near-real time according to the attenuation measured from the previous projection. The profiles gradually stabilized because the tube current was adjusted properly. The absorbed doses were low and the distributions were stable with TCM compared with those without TCM. CONCLUSIONS: In X-ray CT, an online angular TCM can reduce radiation dose effectively by adjusting tube current within one gantry rotation in near-real time.

Neurological deficit after simultaneous open abdominal aortic surgery and thoracic aortic endovascular therapy.

We examined a total of 12 cases; 8 cases were identified by searching the literature on Pubmed (excluding case reports published prior to 2000) and 4 cases were ones we personally encountered. We examined age, sex, history of smoking, and preoperative risk factors as preoperative factors, the access route and coverage of the descending aorta as perioperative factors, and complications and survival time as postoperative factors. Mean coverage of the thoracic aorta was 90.8 mm. In terms of perioperative deaths, 8.3% (1 patient) were due to coagulopathy. Perioperative complications occurred in 16.7% of cases (coagulopathy in 1 patient and paralysis in another). No patients experienced complications or underwent additional treatment during a mean follow-up of 22.9 months. This study suggested that simultaneous open abdominal aortic repair and thoracic aortic endovascular therapy is feasible and also involves few postoperative complications. Paraplegia and paralysis tended to occur less frequently than with two-stage surgery, but further study is needed to explain why this is true.

Prolonged recurrence-free survival following OK432-stimulated dendritic cell transfer into hepatocellular carcinoma during transarterial embolization.

Despite curative locoregional treatments for hepatocellular carcinoma (HCC), tumour recurrence rates remain high. The current study was designed to assess the safety and bioactivity of infusion of dendritic cells (DCs) stimulated with OK432, a streptococcus-derived anti-cancer immunotherapeutic agent, into tumour tissues following transcatheter hepatic arterial embolization (TAE) treatment in patients with HCC. DCs were derived from peripheral blood monocytes of patients with hepatitis C virus-related cirrhosis and HCC in the presence of interleukin (IL)-4 and granulocyte-macrophage colony-stimulating factor and stimulated with 0·1 KE/ml OK432 for 2 days. Thirteen patients were administered with 5 × 106 of DCs through arterial catheter during the procedures of TAE treatment on day 7. The immunomodulatory effects and clinical responses were evaluated in comparison with a group of 22 historical controls treated with TAE but without DC transfer. OK432 stimulation of immature DCs promoted their maturation towards cells with activated phenotypes, high expression of a homing receptor, fairly well-preserved phagocytic capacity, greatly enhanced cytokine production and effective tumoricidal activity. Administration of OK432-stimulated DCs to patients was found to be feasible and safe. Kaplan-Meier analysis revealed prolonged recurrence-free survival of patients treated in this manner compared with the historical controls (P = 0·046, log-rank test). The bioactivity of the transferred DCs was reflected in higher serum concentrations of the cytokines IL-9, IL-15 and tumour necrosis factor-α and the chemokines CCL4 and CCL11. Collectively, this study suggests that a DC-based, active immunotherapeutic strategy in combination with locoregional treatments exerts beneficial anti-tumour effects against liver cancer.

Neurosarcoidosis: radiologic features in five patients.

This paper describes the radiological features in five biopsy-confirmed cases of neurosarcoidosis. The imaging appearance of neurosarcoidosis is highly variable, making the diagnosis difficult on the basis of intracranial images alone. However, if there is evidence of spread along the pia mater, and meningeal mass formation with a lower intensity in the central area and higher intensity in the peripheral area on T2-weighted and FLAIR images, neurosarcoidosis can be considered.

Elective Matsui-Kitamura stent graft repair for descending thoracic aortic aneurysm and chronic type-B aortic dissection.

BACKGROUND: The position of thoracic endovascular aortic repair (TEVAR) compared to open surgery of the thoracic aorta has changed. This study evaluates outcomes after TEVAR performed electively using our original Matsui-Kitamura stent graft (MKSG) to treat descending thoracic aortic aneurysms (dTAA) and chronic type-B aortic dissection (type-B AD), and elucidates the risk factors for postoperative spinal cord ischemia (SCI). METHODS: TEVAR was performed using an MKSG in 66 patients (age: 70.8+/-9.2 years). The underlying etiology was atherosclerotic change in 39 patients, chronic type-B aortic dissection in 23 patients, and other in 4 patients. RESULTS: No perioperative deaths occurred. Three patients showed temporary paralysis due to postoperative SCI. Abdominal aortic aneurysm (AAA) surgery was a risk factor for postoperative SCI (P=0.04). The 5-year survival rate was 81.2%. CONCLUSION: The present study demonstrated that TEVAR of patients with dTAA and chronic type-B AD using an MKSG can be performed with high technical success rates and low rates of severe acute complications. AAA surgery was a risk factor for postoperative SCI.

Case report. Intra-arterial chemotherapy for laryngeal cancer via a non-bifurcating carotid artery.

The common carotid artery (CCA) usually divides into the internal carotid artery (ICA) and the external carotid artery (ECA). We present an extremely rare case of a non-bifurcating carotid artery through which intra-arterial chemotherapy for laryngeal cancer was administered. The CCA angiogram, as well as ultrasonographic evaluation of the carotid arteries, demonstrated a non-bifurcating CCA that subsequently constituted the ICA. Furthermore, several branches normally given off by the ECA arose directly from the single carotid artery. Superselective intra-arterial infusion of cis-diamminedichloroplatinum (II) (CDDP) was subsequently performed.

Anastomosis between the hepatic artery and the extrahepatic collateral or between extrahepatic collaterals: observation on angiography.

Transcatheter arterial chemoembolisation for hepatocellular carcinoma is widely carried out not only through the hepatic artery but also through the extrahepatic collateral pathways. Anatomically, there are many anastomoses between the hepatic artery and the extrahepatic collateral as well as among the extrahepatic collaterals. However, these anastomoses may not be shown on angiography because the anastomosing branches are too small. These anastomoses may not only interfere with effective control of hepatocellular carcinoma by transcatheter arterial chemoembolisation but also cause unexpected procedure-related complications. Therefore, radiologists should have sufficient knowledge of these underlying anastomoses. In this report, we present our angiographic images.

Phase I/II clinical study of percutaneous vertebroplasty (PVP) as palliation for painful malignant vertebral compression fractures (PMVCF): JIVROSG-0202.

BACKGROUND: The safety and efficacy of percutaneous vertebroplasty (PVP), a new treatment modality for painful malignant vertebral compression fractures (PMVCF) using interventional radiology techniques, were evaluated prospectively. MATERIALS AND METHODS: After confirming the absence of safety issues in phase 1, a total of 33 cases were registered up to and including phase 2. Safety and efficacy were evaluated by National Cancer Institute-Common Toxicity Criteria version 2 and Visual Analogue Scale (VAS) at 1 week after PVP. Based on VAS score decreases, efficacy was classified into significantly effective (SE; > or = 5 or reached 0-2), moderately effective (ME; 2-4), or ineffective (NE; <2 or increase). RESULTS: Procedures were completed in all 33 patients (42 vertebrae). Thirty days after PVP, two patients died of primary disease progression, but no major adverse reactions (>grade 2) were observed. Response rate was 70% (95% confidence interval 54% to 83%) [61% (n = 20) with SE, 9% (n = 3) with ME, and 30% (n = 10) with NE] and increased to 83% at week 4. Median time to response was 1 day (mean 2.4). Median pain-mitigated survival period was 73 days. CONCLUSION: For PMVCF, PVP is a safe and effective treatment modality with immediate onset of action.

Comparison between 3-D and z-axis automatic tube current modulation technique in multidetector-row CT.

In this study, the 3-D automatic tube current modulation (3-D ATCM) technique was compared with the z-axis ATCM technique on multidetector-row CT. Absorbed dose measurements were performed by inserting an ion chamber into the phantoms, and objective image noise shown as the standard deviation of CT value in Hounsfield units was measured on the obtained images. The ratio of absorbed doses with 3-D ATCM technique to z-axis ATCM technique was 94.7% using an elliptical cylinder phantom with an inner cylinder phantom and 96.3% using an elliptical cylinder phantom without an inner cylinder phantom. Differences in objective noise between the 3-D ATCM technique and z-axis ATCM technique were within a tolerable range compared with the setting noise index. Therefore, the 3-D ATCM technique effectively optimises the radiation dose, while maintaining an appropriate image quality compared with z-axis ATCM technique.

Improvement of temporal and dynamic subtraction images on abdominal CT using 3D global image matching and nonlinear image warping techniques.

Accurate registration of the corresponding non-enhanced and arterial-phase CT images is necessary to create temporal and dynamic subtraction images for the enhancement of subtle abnormalities. However, respiratory movement causes misregistration at the periphery of the liver. To reduce these misregistration errors, we developed a temporal and dynamic subtraction technique to enhance small HCC by 3D global matching and nonlinear image warping techniques. The study population consisted of 21 patients with HCC. Using the 3D global matching and nonlinear image warping technique, we registered current and previous arterial-phase CT images or current non-enhanced and arterial-phase CT images obtained in the same position. The temporal subtraction image was obtained by subtracting the previous arterial-phase CT image from the warped current arterial-phase CT image. The dynamic subtraction image was obtained by the subtraction of the current non-enhanced CT image from the warped current arterial-phase CT image. The percentage of fair or superior temporal subtraction images increased from 52.4% to 95.2% using the new technique, while on the dynamic subtraction images, the percentage increased from 66.6% to 95.2%. The new subtraction technique may facilitate the diagnosis of subtle HCC based on the superior ability of these subtraction images to show nodular and/or ring enhancement.

A subgroup of intrahepatic cholangiocarcinoma with an infiltrating replacement growth pattern and a resemblance to reactive proliferating bile ductules: 'bile ductular carcinoma'.

AIMS: The histogenesis and biological behaviour of peripheral intrahepatic cholangiocarcinoma (peripheral CC) remain unclarified. The aim of this study was to examine the growth pattern of peripheral CC (24 cases) in comparison with hepatocellular carcinoma (HCC, 27 cases) and metastatic colorectal adenocarcinoma (MCA, 24 cases). METHODS AND RESULTS: Tumour/surrounding liver borders were classified as: (i) fibrous encapsulation, (ii) compressive growth, and (iii) infiltrating replacement. Nineteen of 24 peripheral CCs showed (iii), whereas 23 of 27 HCCs showed (i) and 17 of 24 MCAs showed (ii). In (iii), carcinoma cells infiltrated the surrounding liver without compression, and hepatic supporting vascular structures such as portal tracts were secondarily incorporated into the tumour. In (i) and (ii), the surrounding liver was compressed and no or few portal tracts were incorporated within the tumour. Fifteen of 24 peripheral CCs were composed of carcinoma cells resembling reactive bile ductules and these cells were positive for neural cell adhesion molecule (NCAM), a marker of proliferating bile ductules. The remaining nine peripheral CCs were composed of ordinary adenocarcinoma and negative for NCAM. CONCLUSIONS: A subgroup of peripheral CCs with an infiltrating replacement growth pattern resembles reactive bile ductules and expresses NCAM. 'Bile ductular carcinoma' may be a better term for this subgroup.

Combined therapy of transcatheter hepatic arterial embolization with intratumoral dendritic cell infusion for hepatocellular carcinoma: clinical safety.

The curative treatments for hepatocellular carcinoma (HCC), including surgical resection and radiofrequency ablation (RFA), do not prevent tumour recurrence effectively. Dendritic cell (DC)-based immunotherapies are believed to contribute to the eradication of the residual and recurrent tumour cells. The current study was designed to assess the safety and bioactivity of DC infusion into tumour tissues following transcatheter hepatic arterial embolization (TAE) for patients with cirrhosis and HCC. Peripheral blood mononuclear cells (PBMCs) were differentiated into phenotypically confirmed DCs. Ten patients were administered autologous DCs through an arterial catheter during TAE treatment. Shortly thereafter, some HCC nodules were treated additionally to achieve the curative local therapeutic effects. There was no clinical or serological evidence of adverse events, including hepatic failure or autoimmune responses in any patients, in addition to those due to TAE. Following the infusion of (111)Indium-labelled DCs, DCs were detectable inside and around the HCC nodules for up to 17 days, and were associated with lymphocyte and monocyte infiltration. Interestingly, T lymphocyte responses were induced against peptides derived from the tumour antigens, Her-2/neu, MRP3, hTERT and AFP, 4 weeks after the infusion in some patients. The cumulative survival rates were not significantly changed by this strategy. These results demonstrate that transcatheter arterial DC infusion into tumour tissues following TAE treatment is feasible and safe for patients with cirrhosis and HCC. Furthermore, the antigen-non-specific, immature DC infusion may induce immune responses to unprimed tumour antigens, providing a plausible strategy to enhance tumour immunity.

MR Imaging of Hippocampal Sulcus Remnant: Age-Related Differences.

The hippocampal sulcus remnant (HSR) is often observed at the medial temporal lobe on MR images. In the present study, we made a retrospective assessment of the frequency and age-related differences in HSR in routine brain MR examinations of 1000 patients, 494 females and 506 males. Cases with one or several spots that were hypointense on T1-weighted and FLAIR images and hyperintense on T2-weighted images were defined as positive for HSR. Abnormal spots with the same intensity as cerebrospinal fluid were observed in 210 out of 506 males and in 193 out of 494 females. No significant sex-related differences were observed in the frequency of HSR. The HSR was seen more frequently with age in both males and females. Patients with hypertension had a significantly higher frequency of HSR.

A computer-aided temporal and dynamic subtraction technique of the liver for detection of small hepatocellular carcinomas on abdominal CT images.

It is often difficult for radiologists to identify small hepatocellular carcinomas (HCCs) due to insufficient contrast enhancement. Therefore, we have developed a new computer-aided temporal and dynamic subtraction technique to enhance small HCCs, after automatically selecting images set at the same anatomical position from the present (non-enhanced and arterial-phase CT images) and previous images. The present study was performed with CT images from 14 subjects. First, we used template-matching based on similarities in liver shape between the present (non-enhanced and arterial-phase CT images) and previous arterial-phase CT images at the same position. Temporal subtraction images were then obtained by subtraction of the previous image from the present image taken at the same position of the liver. Dynamic subtraction images were also obtained by subtraction of non-enhanced CT images from arterial-phase CT images taken at the same position of the liver. Twenty-one of 22 nodules (95.5%) with contrast enhancement were visualized in temporal and dynamic subtraction images. Compared with present arterial-phase CT images, increases of 150% and 140% in nodule-to-liver contrast were observed on dynamic and temporal subtraction images, respectively. These subtraction images may be useful as reference images in the detection of small moderately differentiated HCCs.

Lymphoepithelial cyst of the pancreas: case report with special reference to imaging--pathologic correlation.

We report a case of resected lymphoepithelial cyst of the pancreas with special reference to the imaging-pathologic correlation. Visualization of a multilocular cystic nature with internal heterogeneous hyperechogenicity on ultrasound, hyperdensity on precontrast computed tomography, and granular hypointensity on T2-weighted image due to abundant internal keratin substances were considered to be keys to the differential diagnosis from other cystic lesions of the pancreas.

Intraluminal duodenal diverticulum: MR findings.

We report a case of intraluminal duodenal diverticulum with special reference to its magnetic resonance imaging findings. An intraluminal duodenal fluid collection surrounded by a hypointense rim on T2-weighted or magnetic resonance cholangiopancreatographic images, the shape of which is changed by peristalsis, is considered to be almost diagnostic for intraluminal duodenal diverticulum.

Solid serous cystadenoma of the pancreas: MR imaging with pathologic correlation.

We report a case of solid type serous cystadenoma of the pancreas. Computed tomographic and magnetic resonance (MR) images showed a hypervascular solid tumor that was difficult to differentiate from endocrine tumor of the pancreas. However, the tumor showed marked hyperintensity similar to that of hepatic cyst on MR cholangiopancreatography, indicating not a solid but rather a cystic nature. MR cholangiopancreatography (heavily T2-weighted image) is quite useful for clearly differentiating solid from cystic tumors.

MRI findings of primary biliary cirrhosis: correlation with Scheuer histologic staging.

Magnetic resonance imaging (MRI) findings of primary biliary cirrhosis (PBC; currently regarded as a vanishing bile duct syndrome) are not established. In this report, we describe our preliminary analysis of the relation between MRI findings and histopathologic staging of PBC and review clinical, morphologic, and MRI findings of PBC especially focusing on the staging of PBC.