Utility of Carbon Dioxide Venography and Intraprocedural CT for Adrenal Venous Sampling in Patients with an Allergy to Iodinated Contrast Media.

PURPOSE: To assess the diagnostic performance of carbon dioxide (CO2) and intraprocedural unenhanced computed tomography (CT) for adrenal venous sampling (AVS) (CO2-intraprocedural unenhanced CT-AVS) in patients with primary aldosteronism (PA) and a history of iodine contrast medium allergy. MATERIALS AND METHODS: CO2-intraprocedural unenhanced CT-AVS was performed in 18 patients with iodine contrast media allergies at the authors' hospital between December 2015 and January 2021. CT and noncontrast magnetic resonance angiography were used to evaluate the preoperative adrenal vein anatomy. CO2 venography was performed to confirm adrenal vein catheterization. Additionally, intraprocedural unenhanced CT was also performed to confirm catheter position in the right adrenal gland. RESULTS: In all cases in which CO2-intraprocedural unenhanced CT-AVS was performed, the right and left adrenal veins were catheterized appropriately, leading to a localized diagnosis. Catheterization of the left adrenal vein was confirmed using CO2 venography in all cases. In 7 of the 18 cases, CO2 venography demonstrated selection of the right adrenal vein. In 15 of 18 cases, intraprocedural unenhanced CT demonstrated selection of the right adrenal vein. CONCLUSIONS: CO2-intraprocedural unenhanced CT-AVS demonstrated the same diagnostic ability for PA localization as conventional AVS with iodine contrast media. The proposed method is clinically feasible for AVS, in which iodine contrast media use is restricted.

Risk Analysis of Breast Cancer by Using Bilateral Mammographic Density Differences: A Case-Control Study.

The identification of risk factors helps radiologists assess the risk of breast cancer. Quantitative factors such as age and mammographic density are established risk factors for breast cancer. Asymmetric breast findings are frequently encountered during diagnostic mammography. The asymmetric area may indicate a developing mass in the early stage, causing a difference in mammographic density between the left and right sides. Therefore, this paper aims to propose a quantitative parameter named bilateral mammographic density difference (BMDD) for the quantification of breast asymmetry and to verify BMDD as a risk factor for breast cancer. To quantitatively evaluate breast asymmetry, we developed a semi-automatic method to estimate mammographic densities and calculate BMDD as the absolute difference between the left and right mammographic densities. And then, a retrospective case-control study, covering the period from July 2006 to October 2014, was conducted to analyse breast cancer risk in association with BMDD. The study included 364 women diagnosed with breast cancer and 364 matched control patients. As a result, a significant difference in BMDD was found between cases and controls (P < 0.001) and the case-control study demonstrated that women with BMDD > 10% had a 2.4-fold higher risk of breast cancer (odds ratio, 2.4; 95% confidence interval, 1.3-4.5) than women with BMDD ≤ 10%. In addition, we also demonstrated the positive association between BMDD and breast cancer risk among the subgroups with different ages and the Breast Imaging Reporting and Data System (BI-RADS) mammographic density categories. This study demonstrated that BMDD could be a potential risk factor for breast cancer.

Significance of systolic-phase imaging on full-phase ECG-gated CT angiography to detect intimal tears in aortic dissection.

PURPOSE: For patients with aortic dissection (AD) and intramural hematoma (IMH), the optimal cardiac phase to detect intimal tears (IT) and ulcer-like projections (ULP) on retrospective electrocardiogram (ECG)-gated computed tomography angiography (CTA) remains unclear. The purpose of this study was to compare the accuracy of retrospective ECG-gated CTA for detecting IT in AD and ULP in IMH between each cardiac phase. MATERIALS AND METHODS: A total of 75 consecutive patients with AD and IMH of the thoracic aorta were enrolled in this single-center retrospective study. The diagnostic performance to detect IT and ULP in the thoracic aortic regions (including the ascending aorta, aortic arch, and proximal and distal descending aorta) was compared in each cardiac phase on retrospective ECG-gated CTA. RESULTS: In the systolic phase (20%), the accuracy, sensitivity, and specificity to detect IT in AD was 64% (95% confidence interval [CI] 56-72%), 69% (95%CI 60-78%), and 25% (95%CI 3.3-45%), respectively. In the diastolic phase (70%), the accuracy, sensitivity, and specificity to detect IT in AD was 52% (95%CI 43-60%), 52% (95%CI 42-61%), and 50% (95%CI 25-75%), respectively. The accuracy to detect IT in AD on ECG-gated CTA was significantly higher in the systolic phase than that in the diastolic phase (P = 0.025). However, there were no differences in the accuracy (83%; 95%CI 78-89%), sensitivity (71%; 95%CI 62-80%), or specificity (100%; 95%CI 100%) to detect ULP in IMH between the cardiac cycle phases. CONCLUSION: Although it is currently recommended for routine diagnosis of AD and IMH, single-diastolic-phase ECG-gated CTA has risk to miss some IT in AD that are detectable in the systolic phase on full-phase ECG-gated CTA. This information is critical for determining the optimal treatment strategy for AD.

Leptomeningeal carcinomatosis from breast cancer initially mimicking cerebral infarction on MRI.

A female patient in her early 50s with breast cancer underwent breast-conserving surgery, followed by radiation therapy. She developed multiple lung and bone metastases and was started on chemotherapy with bevacizumab and paclitaxel 3 years later. After 6 months of chemotherapy, she developed a decline in conversation and memory. Magnetic resonance imaging (MRI) was conducted and showed multiple cortical and subcortical lesions and nodules with restricted diffusion but with no contrast enhancement on gadolinium (Gd) enhanced T1-weighted image, raising a suspicion of Trousseau's syndrome. A follow-up MRI revealed unchanged signal intensity of the lesions but with minimal enlargement. The cerebrospinal fluid cytology was negative for malignancy. Consequently, an open biopsy of the cortical lesion was conducted. Histopathology showed that the tumor cells were morphologically similar to the primary breast cancer extending from the brain surface along the Virchow-Robin spaces, which yielded a diagnosis of leptomeningeal carcinomatosis from breast cancer. Contrast enhancement on Gd-MRI may be impaired in case of tumor spread along the perivascular space or in patients treated with bevacizumab.

Cost-effectiveness analysis of segmental adrenal venous sampling with radiofrequency ablation for primary aldosteronism in Japan.

PURPOSE: The purpose of this study was to evaluate the cost-effectiveness of comprehensive treatment strategy, including segmental adrenal venous sampling (sAVS) and radiofrequency ablation (RFA), versus medication-only strategy for primary aldosteronism. MATERIALS AND METHODS: A Markov decision model was developed to compare the cost-effectiveness of a comprehensive treatment strategy and a medication-only strategy for 50-year-old men and women with stage I-III hypertension. The comprehensive treatment strategy included aldosterone/renin ratio measurement, two loading tests, computed tomography, sAVS, drugs, surgery, and RFA. We built a model with a yearly cycle over 32- and 38-year time horizons for men and women, respectively, and four health states: hypertension, heart failure, stroke, and death. The incremental cost-effectiveness ratio (ICER), expressed as Japanese yen per quality-adjusted life-years (QALYs), was estimated, and strategy preference was determined on the basis of 5 million Japanese yen per QALY societal willingness-to-pay threshold. RESULTS: The ICERs of the comprehensive treatment strategy over the medication-only strategy were 201,482 and 3,399 JPY per QALY for men and women, respectively. The resultant ICER was less than the 5 million JPY societal willingness-to-pay threshold. Deterministic sensitivity analysis and probabilistic sensitivity analysis revealed that the results varied with the input values, but the comprehensive strategy was likely to be more cost-effective than the medication-only strategy. CONCLUSION: This cost-effectiveness study revealed that a comprehensive treatment strategy including sAVS and RFA was favorable compared with the medication-only strategy for managing stage I-III hypertension in 50-year-old men and women, with acceptable willingness-to-pay thresholds. This cost-effectiveness study revealed that a comprehensive treatment strategy for primary aldosteronism that included segmental adrenal sampling and radiofrequency ablation was favorable compared with the medication-only strategy for managing stage I-III hypertension in 50-year-old men and women, with acceptable willingness-to-pay thresholds.

A case of percutaneous transhepatic portal vein stenting without using iodinated contrast media for post pancreatectomy portal vein obstruction.

Postoperative portal vein obstruction could occur as a complication of portal vein reconstruction during hepatic lobectomy or pancreaticoduodenectomy. We report a case of patient with postoperative portal vein obstruction treated with percutaneous transhepatic portal vein stenting without using iodinated contrast media owing to a history of severe allergic reactions. Under ultrasound guidance, carbon dioxide angiography, and appropriate device selection, successful stenting was achieved without serious adverse events. After the operation, portal vein blood flow and clinical symptoms improved, enabling adjuvant chemotherapy. To the best of our knowledge, this is the first case report wherein percutaneous transhepatic portal vein stenting was successfully performed in a patient with an iodine allergy.

Transvenous Radiofrequency Catheter Ablation for an Aldosterone-Producing Tumor of the Left Adrenal Gland: A First in Human Case Report.

PURPOSE: To describe a novel technique of transvenous radiofrequency catheter ablation of an aldosterone-producing adenoma (APA) of the left adrenal gland using the GOS System (Japan Lifeline, Tokyo, Japan). Using the GOS system, a flexible radiofrequency tip catheter can be inserted into the adrenal central and tributary veins, the drainers for functional tumors. MATERIALS AND METHODS: An APA at the left adrenal gland, which was diagnosed by segmental adrenal venous sampling following administration of 0.25 mg cosyntropin, was ablated using the GOS catheter inserted into adrenal tributary veins via a right femoral vein 7-Fr sheath. The effect of radiofrequency ablation on APA was assessed using the international consensus on surgical outcomes for unilateral primary aldosteronism (PA). RESULTS: No device-related complications were observed. The patient was deeply sedated under blood pressure and heart rate control with continuous administration of ß-blockers. Then, the tumor and surrounding adrenal gland were cauterized at 7000 J two times each in sequence. The output time was 7-11 min for each ablation and 80 min in total. For blood pressure and pulse rate control, esmolol hydrochloride and phentolamine mesylate were used. The contrast enhancement of APA disappeared on dynamic CT immediately after the procedure. PA was biochemically cured until 12 months after the procedure. CONCLUSION: Using the radiofrequency device with the GOS catheter and system is a method for cauterizing adrenal tumors from blood vessels. This approach resulted in a marked reduction in aldosterone concentrations and a complete biochemical cure of PA over the observation period.

Detection of the intimal tear in aortic dissection and ulcer-like projection in intramural hematoma: usefulness of full-phase retrospective ECG-gated CT angiography.

PURPOSE: To compare the accuracy of non-electrocardiogram (ECG)-gated CT angiography (CTA), single-diastolic-phase ECG-gated CTA, and full-phase ECG-gated CTA in detecting the intimal tear (IT) in aortic dissection (AD) and ulcer-like projection (ULP) in intramural hematoma (IMH). MATERIALS AND METHODS: A total of 81 consecutive patients with AD and IMH of the thoracic aorta were included in this single-center retrospective study. Non-ECG-gated CTA, single-diastolic-phase ECG-gated CTA, and full-phase ECG-gated CTA were used to detect the presence of the IT and ULP in thoracic aortic regions including the ascending aorta, aortic arch, and proximal and distal descending aorta. RESULTS: The accuracy of detecting the IT and ULP was significantly greater using full-phase ECG-gated CTA (88% [95% CI: 100%, 75%]) than non-ECG-gated CTA (72% [95% CI: 90%, 54%], P = 0.001) and single-diastolic-phase ECG-gated CTA (76% [95% CI: 93%, 60%], P = 0.008). CONCLUSION: Full-phase ECG-gated CTA is more accurate in detecting the IT in AD and ULP in IMH, than non-ECG-gated CTA and single-diastolic-phase ECG-gated CTA.