Asymmetric Total Synthesis of (-)-Astakolactin and Confirmation of Its Stereostructure.

The originally proposed structure of astakolactin was revised, and an asymmetric total synthesis of the newly proposed structure was achieved. The key transformations in the synthesis were a Johnson-Claisen rearrangement, an asymmetric Mukaiyama aldol reaction, and a Mitsunobu-type cyclodehydration. The spectroscopic data and specific rotation of the compound obtained matched well with those reported for naturally occurring astakolactin.

Value of Percutaneous Radiologic Gastrostomy for Patients with Advanced Esophageal Cancer.

BACKGROUND: Nutritional management is important throughout the treatment period for esophageal cancer patients. This study aimed to evaluate the feasibility of percutaneous radiologic gastrostomy (PRG) and to investigate whether PRG can be applied for patients with advanced esophageal cancer. METHODS: In this study, 89 patients (74 men and 15 women) with advanced esophageal cancer underwent PRG using computed tomography and fluoroscopic guidance. These patients were unsuitable candidates for endoscopic intervention because of esophageal stricture. Primary placement of a mushroom-retained gastrostomy catheter was intended. The end points were technical success and complications after PRG as well as clinical outcomes and survival of the patients. These end points also were compared between the pre-chemoradiotherapy (pre-CRT) and post-CRT groups using the Chi square test, Fisher's exact test, and the Wilcoxon rank sum test. The survival rate was calculated using the Kaplan-Meier method and compared using the log-rank test. RESULTS: All the patients had a successful PRG. The mushroom-tip gastrostomy catheter was primarily inserted in 77 patients (86.5 %) and finally achieved for all the patients. Complications occurred for 14 patients (15.7 %) including Dindo-Clavien classification grade 3 (1 catheter dislodgement), grade 2 (2 gastric hemorrhages), and grade 1 (7 skin infections and 4 oozing hemorrhages) complications. During the follow-up period (median, 6 months), 60 patients (67.4 %) died, giving a 12-month survival rate of 37.7 %. Gastrostomy removal was more common in the pre-CRT group (P = 0.011). The pre-CRT group had higher survival rates than the post-CRT group (P = 0.021). CONCLUSIONS: Because PRG provided high technical success with limited complications, it can be used for patients with advanced esophageal cancer whose treatment plan involves multimodal therapy.

Cost-Effectiveness Analysis of Percutaneous Sclerotherapy for Venous Malformations.

PURPOSE: To assess cost-effectiveness of sclerotherapy for venous malformations (VMs) to improve patient quality of life (QOL). MATERIALS AND METHODS: This prospective study enrolled 28 patients with symptomatic VMs who underwent sclerotherapy. EuroQol-5 Dimension (EQ-5D) and Short-Form 36 (SF-36) Health Survey were used to measure health-related QOL. Questionnaires were collected before and 1, 3, 6, and 12 months after sclerotherapy. Quality-adjusted life years (QALYs) were calculated using EQ-5D score as a measure of health utility. Medical costs obtained from the hospital accounting system and other costs of staff, drugs, materials, and angiographic equipment were calculated for each procedure. Cost-effectiveness was analyzed using incremental cost-effectiveness ratio (ICER) as the medical cost/gain of QALYs. RESULTS: Median EQ-5D scores improved from 0.768 (range, 0.705-1) to 1 (range, 0.768-1) after 6 months (P = .023) and 1 (range, 0.768-1) after 12 months (P = .063). The gain of QALYs at 12 months was 0.043. The mean medical cost was ¥281,228 ($2,337). The pain group (baseline bodily pain scale of SF-36 score < 70) showed greater improvement in median EQ-5D score, from 0.705 (range, 0.661-0.768) to 0.768 (range, 0.705-1) after 6 months (P = .041) and 0.768 (range, 0.768-1) after 12 months (P = .049). ICER at 12 months was ¥6,600,483 ($54,840) in the overall group and decreased to ¥3,998,113 ($33,218) in the pain group, < ¥6,000,000 ($49,850), threshold for acceptance of a public health benefit in Japan, even accounting for 50% increase in costs. CONCLUSIONS: Sclerotherapy was cost-effective for improving QOL for symptomatic VMs, especially for patients with moderate to severe pain.

Does Gadoxetic acid-enhanced 3.0T MRI in addition to 64-detector-row contrast-enhanced CT provide better diagnostic performance and change the therapeutic strategy for the preoperative evaluation of colorectal liver metastases?

OBJECTIVES: To compare diagnostic performance in the detection of colorectal liver metastases between 64-detector-row contrast-enhanced CT (CE-CT) alone and the combination of CE-CT and gadoxetic acid-enhanced MRI (EOB-MRI) at 3.0T, and to assess whether EOB-MRI in addition to CE-CT results in a change to initially planned operative strategy. METHODS: A total of 39 patients (27 men, mean age 65 years) with 85 histopathologically confirmed liver metastases were included. At EOB-MRI, unenhanced (T1- and T2-weighted), dynamic, and hepatocyte-phase images were obtained. At CE-CT, four-phase dynamic contrast-enhanced images were obtained. One on-site reader and three off-site readers independently reviewed both CE-CT alone and the combination of CE-CT and EOB-MRI. Sensitivity, positive predictive value, and alternative free-response receiver operating characteristic (AFROC) method were calculated. Differences in therapeutic strategy before and after the EOB-MRI examination were also evaluated. RESULTS: Sensitivity and area under the AFROC curve with the combination of CE-CT and EOB-MRI were significantly superior to those with CE-CT alone. Changes in surgical therapy were documented in 13 of 39 patients. CONCLUSIONS: The combination of CE-CT and EOB-MRI may provide better diagnostic performance than CE-CT alone for the detection of colorectal liver metastases, and EOB-MRI in addition to CE-CT resulted in changes to the planned operative strategy in one-third of the patients. KEY POINTS: • Accurate preoperative imaging is essential for surgical planning and successful hepatic resection. • Combination of CE-CT and EOB-MRI is useful to detect colorectal liver metastases. • EOB-MRI combined with CE-CT contributes to determine the correct therapeutic strategy.

Infusion of 50% glucose solution to occlude an intrahepatic portosystemic venous shunt before percutaneous transhepatic portal embolization: report of a case.

A 68-year-old man with cholangiocarcinoma underwent percutaneous transhepatic portal embolization to expand the indication for hepatic resection. Selective right posterior portography revealed an intrahepatic portosystemic venous shunt (IPSVS) connecting the segment VII branch to the right hepatic venous branch. An infusion of 50 % glucose solution was given to occlude the shunt. This is novel management for IPSVSs when they are numerous, small, or torturous, and makes the subsequent procedures simpler, shorter, and less expensive.

Assessment of the interface between retroperitoneal fat infiltration of pancreatic ductal carcinoma and the major artery by multidetector-row computed tomography: surgical outcomes and correlation with histopathological extension.

BACKGROUND: Precise assessment of retroperitoneal invasion is clinically important to allow the achievement of negative margin resections. METHODS: The clinical records of 132 patients who underwent macroscopic curative pancreaticoduodenectomy for invasive ductal carcinoma of the pancreas between 2004 and 2008 were retrospectively examined. The clinicopathological factors, including retroperitoneal fat infiltration classified into four groups by multidetector-row computed tomography (MDCT), were analyzed. The relationship between the grade of retroperitoneal fat infiltration and surgical outcomes, as well as various histopathological factors, was also investigated. RESULTS: The 5 year survival rate was 55.6 % for grade 0 infiltration (n = 8), 38.7 % for grade 1 (n = 54), 16.4 % for grade 2 (n = 49), and 0 % for grade 3 (n = 21). There were significant differences in survival in each group. Extrapancreatic nerve invasion and the surgical margin status were significantly associated with retroperitoneal fat infiltration demonstrated on MDCT. According to the grading classification among the 43 patients with pathological portal vein invasion, the 5 year survival rate was 45.9 % for patients with grade 1, which was significantly better survival that those with grade 2 (P = 0.007). CONCLUSION: The grading criteria for retroperitoneal fat infiltration may be useful as a predictor of survival after pancreaticoduodenectomy for pancreatic head carcinoma. Pancreaticoduodenectomy with portal vein resection could provide favorable survival in patients with grade 1 retroperitoneal fat infiltration, even if histopathological portal vein invasion is present.

Technique for creation of artificial pneumothorax for pain relief during radiofrequency ablation of peripheral lung tumors: report of seven cases.

This report describes seven cases in which a pneumothorax was artificially created for relief from severe pain that occurred during radiofrequency (RF) ablation of peripheral lung tumors. In this procedure, the multitined probe surrounding the lesion was advanced into the chest, displacing the tines and the peripheral tumor away from the parietal pleura and the chest wall and resulting in pain relief in one patient; in the remaining patients, an intravenous catheter was also introduced, followed by the administration of carbon dioxide (CO(2)) into the space between the tumor and the parietal pleura. The pain decreased considerably immediately after this procedure. No complication related to the creation of the artificial pneumothorax was observed. Creation of an artificial pneumothorax is a safe and effective method for pain relief.

Feasibility, safety, and efficacy of artificial carbon dioxide pneumothorax for computed tomography fluoroscopy-guided percutaneous radiofrequency ablation of hepatocellular carcinoma.

PURPOSE: To retrospectively assess the feasibility, safety, and efficacy of artificial carbon dioxide (CO2) pneumothorax for computed tomography (CT) fluoroscopy-guided percutaneous radiofrequency (RF) ablation of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: This study included 26 sessions of 24 patients in whom the creation of artificial CO2 pneumothorax was attempted to avoid the transpulmonary route during CT fluoroscopy-guided percutaneous RF ablation of HCC between April 2011 and December 2017. In these 26 sessions, 29 HCCs (mean tumor diameter: 12 mm, range: 6-22 mm) were treated. RESULTS: Adequate lung displacement after induction of artificial CO2 pneumothorax was achieved in 23 of the 26 sessions (88.5%). In the remaining three sessions, transpulmonary RF ablation, transthoracic extrapulmonary RF ablation after switching to an artificial pleural effusion procedure, or RF ablation with electrode insertion in the caudal-cranial oblique direction was performed. No major complications were found. Among the 29 treated tumors, one (3.4%) showed local progression, and the other 28 (96.6%) were completely ablated at the last follow-up (mean follow-up period: 39.3 months, range: 7-78 months). CONCLUSION: Artificial CO2 pneumothorax for CT fluoroscopy-guided percutaneous RF ablation appeared to be a feasible, safe, and useful therapeutic option for HCC.

Magnetic resonance imaging findings of a myxoid leiomyosarcoma of the uterus: A case report and literature review.

Uterine myxoid leiomyosarcomas (MLMSs) are extremely rare. Here, we report a rare case of uterine MLMS with unique and bizarre magnetic resonance imaging (MRI) findings on diffusion-weighted images (DWIs) and dynamic contrast-enhanced (DCE) MRI scans. A 67-year-old woman presented with a uterine MLMS that had a multilocular cystic mass with a septum and solid components. The tumour demonstrated marked hyperintensity on T2-weighted images in a myxoid stroma with gradual partial contrast enhancement and diffusion restriction, which could be a characteristic feature suggestive of a myxoid malignant smooth muscle tumour of the uterus rather than a uterine leiomyoma with myxoid degeneration.

Brachial nerve injury caused by percutaneous radiofrequency ablation of apical lung cancer: a report of four cases.

The present report describes four cases of brachial nerve injury caused by percutaneous radiofrequency (RF) ablation of lung cancer. All the tumors were located in the lung apex. The patients developed symptoms indicative of a low brachial plexus injury during RF ablation or as long as 7 days afterward. These symptoms partially receded over time. The indications of RF ablation in patients with apical lung cancer should be carefully determined because of the risk of brachial nerve injury associated with the procedure.

Incidence of and risk factors for pneumothorax and chest tube placement after CT fluoroscopy-guided percutaneous lung biopsy: retrospective analysis of the procedures conducted over a 9-year period.

OBJECTIVE: The objective of our study was to retrospectively evaluate the incidence of and the risk factors for pneumothorax and chest tube placement after CT fluoroscopy-guided lung biopsy. MATERIALS AND METHODS: We analyzed 1,098 CT fluoroscopy-guided lung biopsies conducted with 20-gauge coaxial cutting needles for 1,155 lesions in 1,033 patients. Apart from evaluating the incidence of pneumothorax and chest tube placement, the independent risk factors for pneumothorax and chest tube placement for pneumothorax were determined using multivariate logistic regression analysis. RESULTS: The overall incidence of pneumothorax was 42.3% (464/1,098). Chest tube placement was required for 11.9% (55/464) of pneumothoraces (5.0% [55/1,098] of the total number of procedures). The significant independent risk factors for pneumothorax were no prior pulmonary surgery (p = 0.001), lesions in the lower lobe (p < 0.001), greater lesion depth (p < 0.001), and a needle trajectory angle of < 45 degrees (p = 0.014); those for chest tube placement for pneumothorax were pulmonary emphysema (p < 0.001) and greater lesion depth (p < 0.001). CONCLUSION: Pneumothorax frequently occurred and placement of a chest tube was occasionally required for pneumothorax after CT fluoroscopy-guided lung biopsy. To reduce the risk of pneumothorax necessitating chest tube placement, physicians should adopt the shortest needle path to the lesion.

Bridging stent placement through the superior vena cava to the inferior vena cava in a patient with malignant superior vena cava syndrome and an iodinated contrast material allergy.

Positioning is critical during the placement of superior vena cava (SVC) stents in patients with malignant SVC syndrome. Although SVC stents effectively relieve various symptoms of SVC syndrome, improper stent positioning may cause life-threatening complications such as migration that result in fatal cardiac failure. Here we describe a patient with an allergy to iodinated contrast material (ICM) who presented with SVC syndrome owing to mediastinal lymph node metastases from hepatocellular carcinoma, which was successfully treated with an SVC stent. Secure stent placement was achieved by bridging the stent through the SVC to the inferior vena cava with venography using carbon dioxide instead of ICM.

A case of autoimmune pulmonary alveolar proteinosis appearing as a localized ground-glass opacity.

Pulmonary alveolar proteinosis (PAP) is a rare diffuse lung disease caused by abnormal intra-alveolar surfactant accumulation; it commonly appears as a "crazy-paving" pattern on high-resolution computed tomography. Here, we report a rare case of autoimmune PAP appearing as localized ground-glass opacity. An 82-year-old woman underwent chest computed tomography (CT) at another facility for cough, and a 2-cm localized ground-glass opacity was detected at the bottom of the right upper lung lobe. When she presented for follow-up at our hospital 6 months later, she was asymptomatic. The CT examinations performed at that point and 2 months thereafter did not reveal any changes. However, a CT examination performed after 5 months revealed slight increases in size and concentration. Adenocarcinoma in situ or minimally invasive adenocarcinoma was suspected. Incomplete lobulation between the upper and middle lobes of the right lung was detected, and video-assisted thoracoscopic lobectomy of the upper lobe and partial resection of the middle lobe of the right lung were performed. Histological examination revealed alveoli and terminal bronchioles filled with eosinophilic proteinaceous material positive for periodic acid-Schiff stain. The histopathological diagnosis was PAP and positive serum anti-GM-CSF antibody findings confirmed autoimmune PAP.

Successful balloon-occluded retrograde transvenous obliteration for bleeding duodenal varices using cyanoacrylate.

A 76-year-old woman with hepatitis C cirrhosis presented with tarry stools and hematemesis. An endoscopy demonstrated bleeding duodenal varices in the second portion of the duodenum. Contrast-enhanced computed tomography revealed markedly tortuous varices around the wall in the duodenum. Several afferent veins appeared to have developed, and the right ovarian vein draining into the inferior vena cava was detected as an efferent vein. Balloon-occluded retrograde transvenous obliteration (BRTO) of the varices using cyanoacrylate was successfully performed in combination with the temporary occlusion of the portal vein. Although no previous publications have used cyanoacrylate as an embolic agent for BRTO to control bleeding duodenal varices, this strategy can be considered as an alternative procedure to conventional BRTO using ethanolamine oleate when numerous afferent vessels that cannot be embolized are present.

CT fluoroscopy-guided cutting needle biopsy of focal pure ground-glass opacity lung lesions: diagnostic yield in 83 lesions.

OBJECTIVE: The objective of our study was to retrospectively determine the diagnostic yield of CT fluoroscopy-guided cutting needle biopsy of focal pure ground-glass opacity lung lesions. MATERIALS AND METHODS: Biopsies were performed using 20-G coaxial cutting needles for 83 focal pure ground-glass opacity lung lesions (mean lesion size, 12.1mm). After excluding the lesions for which biopsy specimens were unobtainable and final diagnoses were undetermined, the diagnostic yield, including sensitivity and specificity for a diagnosis of malignancy and accuracy, was calculated. The lesions were then divided into 2 groups: the diagnostic failure group, comprising lesions with false-negative results and for which a biopsy specimen was unobtainable; and the diagnostic success group, comprising lesions with true-negative results and true-positive results. Various variables were compared between the 2 groups by univariate analysis. RESULTS: Biopsy specimens were obtained from 82 lesions, while specimens could not be obtained from 1 lesion. Final diagnosis was undetermined in 16 lesions. The sensitivity and specificity for a diagnosis of malignancy were 95% (58/61) and 100% (5/5), respectively. Diagnostic accuracy was 95% (63/66). The 4 lesions in diagnostic failure group were smaller, deeper, and more likely to be located in the lower lobe and further, for those lesions, number of specimens obtained was smaller, compared with 63 lesions in diagnostic success group. However, none of the differences were statistically significant. CONCLUSION: CT fluoroscopy-guided cutting needle biopsy provided high diagnostic yield for focal pure ground-glass opacity lung lesions.

Presence of EGFR mutation in pathologically non-malignant specimens from computed tomography-guided lung needle biopsies.

Activating mutations of the epidermal growth factor receptor (EGFR) gene are characteristic of non-small cell lung cancer (NSCLC). EGFR mutations were previously detected in histologically normal lung tissue around NSCLC tumors. Computed tomography-guided lung needle biopsy (CTNB) is an accurate and useful technique for the diagnosis of lung tumors. However, pathologically non-malignant cases occasionally become apparent following lung tumor resection. In this study, we determined the EGFR mutational status of lung tumors diagnosed as non-malignant in CTNB specimens, but diagnosed as NSCLC following surgical resection. Between 2000 and 2008, 1,109 CTNBs were performed at Okayama University Hospital. Among them, 15 cases were initially diagnosed as non-malignant by CTNB, but diagnosed as NSCLC following surgical resection as a result of a high likelihood of malignancy by clinical findings. Twelve paired DNAs of CTNB and corresponding resected specimens were available to examine the EGFR mutational status using a mutant-enriched PCR assay. EGFR mutations were detected in one out of 12 CTNB specimens and three of the corresponding resected tumors. This case harbored the same EGFR mutation in the CTNB specimen and resected tumor, but not in the distant corresponding non-malignant lung tissue. Our results indicated that the detection of EGFR mutations may therefore aid the diagnosis of NSCLC in pathologically non-malignant CTNB specimens.