Use of (18)F-FDG PET to predict tumor progression and survival in patients with intermediate hepatocellular carcinoma treated by transarterial chemoembolization.

BACKGROUND/AIMS: (18)F-Fluorodeoxyglucose positron-emission tomography ((18)F-FDG PET) has been used to assess the biological behavior of hepatocellular carcinoma (HCC). In this study, we investigated the usefulness of (18)F-FDG PET for predicting tumor progression and survival in patients with intermediate Barcelona Clinic Liver Cancer (BCLC) intermediate-stage HCC treated by transarterial chemoembolization (TACE). METHODS: From February 2006 to March 2013, 210 patients treated with TACE, including 77 patients with BCLC intermediate-stage HCC, underwent examination by (18)F-FDG PET. (18)F-FDG uptake was calculated based on the tumor maximum (Tmax) standardized uptake value (SUV), the liver mean (Lmean) SUV, and the ratio of the Tmax SUV to the Lmean SUV (Tmax/Lmean). RESULTS: The mean follow-up period for the 77 patients (52 males, 25 females; average age, 63.3 years) was 22.2 months. The median time to progression of HCC in patients with a low Tmax/Lmean (< 1.83) and high Tmax/Lmean (≥ 1.83) was 17 and 6 months, respectively (p < 0.001). The median overall survival time of patients with a low and high Tmax/Lmean was 44 and 14 months, respectively (p = 0.003). Multivariate analysis revealed that the Tmax/Lmean was an independent predictor of overall survival (hazard ratio [HR], 1.96; 95% confidence interval [CI], 1.210 to 3.156; p = 0.006) and tumor progression (HR, 2.05; 95% CI, 1.264 to 3.308; p = 0.004). CONCLUSIONS: (18)F-FDG uptake calculated by the Tmax/Lmean using PET predicted tumor progression and survival in patients with BCLC intermediate-stage HCC treated by TACE.

Diagnostic value for extrahepatic metastases of hepatocellular carcinoma in positron emission tomography/computed tomography scan.

AIM: To evaluated the value of ¹8F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) scan in diagnosis of hepatocellular carcinoma (HCC) and extrahepatic metastases. METHODS: A total of 138 patients with HCC who had both conventional imaging modalities and ¹8F-FDG PET/CT scan done between November 2006 and March 2011 were enrolled. Diagnostic value of each imaging modality for detection of extrahepatic metastases was evaluated. Clinical factors and tumor characteristics including PET imaging were analyzed as indicative factors for metastases by univariate and multivariate methods. RESULTS: The accuracy of chest CT was significantly superior compared with the accuracy of PET imaging for detecting lung metastases. The detection rate of metastatic pulmonary nodule ≥ 1 cm was 12/13 (92.3%), when < 1 cm was 2/10 (20%) in PET imaging. The accuracy of PET imaging was significantly superior compared with the accuracy of bone scan for detecting bone metastases. In multivariate analysis, increased tumor size (≥ 5 cm) (P = 0.042) and increased average standardized uptake value (SUV) uptake (P = 0.028) were predictive factors for extrahepatic metastases. Isometabolic HCC in PET imaging was inversely correlated in multivariate analysis (P = 0.035). According to the receiver operating characteristic curve, the optimal cutoff of average SUV to predict extrahepatic metastases was 3.4. CONCLUSION: ¹8F-FDG PET/CT scan is invaluable for detection of lung metastases larger than 1 cm and bone metastases. Primary HCC having larger than 5 cm and increased average SUV uptake more than 3.4 should be considered for extrahepatic metastases.

Congenital hypothyroidism: analysis of discordant US and scintigraphic findings.

PURPOSE: To retrospectively review discordant cases of congenital hypothyroidism according to a comparison of findings of ultrasonography (US) and scintigraphy. MATERIALS AND METHODS: Institutional review board approval was obtained for this retrospective study with a waiver of informed consent. Data of 300 pediatric patients (mean age, 4.7 weeks; range, 1-48 weeks; male-to-female ratio, 169:131) with congenital hypothyroidism who underwent technetium 99m radioisotope scintigraphy and US were reviewed. Scintigraphic scans were analyzed for location and range of the radioisotope uptake. US images were analyzed for location and thyroid volume. If a normal thyroid was not detected, ectopic thyroid was evaluated. Detection of focal thyroid abnormalities was recorded. Correlation between radioisotope uptake at scintigraphy and volume of normally located glands measured at US was analyzed by using the Pearson correlation test. Differences between results of thyroid function testing and radiologic data among subtypes of congenital hypothyroidism were analyzed with analysis of variance and Scheffe multiple comparison test. RESULTS: Among 55 patients with no radioisotope uptake, the appearance of the thyroid gland on US scans was normal in 42 patients (76%). This finding was attributed to hypopituitarism (n = 3), maternal antibody-induced hypothyroidism (n = 4), transient elevated thyrotropin (n = 5), and unknown causes (n = 30). Ectopic tissue was not detected at US (sensitivity, 78%; specificity, 100%) in six patients with a diagnosis of ectopy based on scintigraphic findings. Correlation between radioisotope uptake and US thyroid volume was statistically significant (P < .001). Correlation of results from thyroid function testing (thyrotropin, thyroxine, thyroglobulin) and radiologic data (radioisotope uptake, US measurement of volume) with subtypes of congenital hypothyroidism was significant (P < .001). Solid thyroid nodules were present in the thyroid gland in 0.7% (two of 300) of cases. CONCLUSION: Use of both scintigraphy and US results in a more complete depiction of neonatal congenital hypothyroidism than either test alone.

Bilateral breast enlargement: an unusual presentation of superior vena cava obstruction in a hemodialysis patient with fibrosing mediastinitis.

A 67-year-old woman with end-stage renal disease presented with profound edema of both breasts. The presence of a patent hemodialysis basilic transposition fistula and superior vena cava obstruction (SVC), due to fibrosing mediastinitis, was demonstrated by the use of fistulography. Endovascular treatment with a balloon and stent caused immediate resolution of the breast edema.

Acute diffuse phlegmonous esophagogastritis: a case report.

Acute phlegmonous infection of the gastrointestinal tract is characterized by purulent inflammation of the submucosa and muscular layer with sparing of the mucosa. The authors report a rare case of acute diffuse phlegmonous esophagogastritis, which was well diagnosed based on the typical chest computed tomographic (CT) findings and was successfully treated. A 48-yr-old man presented with left chest pain and dyspnea for three days. Chest radiograph on admission showed mediastinal widening and bilateral pleural effusion. The patient became febrile and the amount of left pleural effusion is increased on follow-up chest radiograph. Left closed thoracostomy was performed with pus drainage. A CT diagnosis of acute phlegmonous esophagogastritis was suggested and a surgery was decided due to worsening of clinical condition of the patient and radiologic findings. Esophageal myotomies were performed and the submucosal layer was filled with thick, cheesy materials. The patient was successfully discharged with no postoperative complication.

Use of a rosch-uchida needle for recanalization of refractory dialysis-related central vein occlusion.

OBJECTIVE: The purpose of this study was to evaluate our experience with the use of a Rösch-Uchida needle technique to recanalize central vein occlusion that cannot be traversed with a guidewire. MATERIALS AND METHODS: We retrospectively evaluated 33 recanalization procedures performed with a Rösch-Uchida needle on 20 men and 13 women with central vein occlusion during the period January 1999-December 2008. The occlusions were in the subclavian vein (n = 29) and the brachiocephalic vein (n = 4). A 9- or 10-French Rösch-Uchida introducer sheath was advanced centrally to abut the occlusion. The Rösch-Uchida needle was directed and advanced toward a transfemoral angiographic catheter placed on the central side of the occlusion. After passage of a guidewire through the occlusion, balloon angioplasty and stent insertion were performed. The outcome measures evaluated were technical success rate, primary and secondary patency, and complication rate. RESULTS: The mean occlusion length was 1.73 +/- 0.8 cm. The rate of technical success of recanalization was 93.9% (31 of 33 procedures). The 3-, 6-, and 12-month primary patency rates were 43.6%, 24%, and 8%, and the 3-, 6-, and 12-month secondary patency rates were 77.4%, 68.8% and 55.9%. One patient reported shoulder pain lasting 2 weeks, which resolved with conservative treatment. CONCLUSION: Use of a Rösch-Uchida needle to recanalize central vein occlusion refractory to a traditional procedure is feasible and safe and can preserve the involved extremity for long-term hemodialysis.

Tumor detection and serosal invasion of bladder cancer: role of three-dimensional volumetric reconstructed US.

BACKGROUND: Accurate evaluation of local extent in bladder cancer is important to determine the optimal therapeutic strategy and to predict the outcome of treatment. The purpose of this study is to evaluate the accuracy of 3D volumetric reconstructed US in the assessment of tumor detection and serosal invasion in patients with bladder cancer. METHODS: A total of 14 patients with findings of bladder cancer determined with the use of cystoscopy was examined with the use of bladder two-dimensional (2D) US and subsequent 3D US. US findings were compared with cystoscopy findings and the pathological stage after a TURB or a radical cystectomy in a double-blinded manner. RESULTS: The sensitivity of preoperative tumor staging was 67.9% for 2D US and sensitivity was 78.6% for 3D US. 3D US was superior sensitivity than 2D US (P < 0.05). The accuracy for serosal invasion in staging of bladder cancer was demonstrated for 88.9% in 2D US and for 100% in 3D US. CONCLUSIONS: The accuracy for serosal invasion (T3b) in the staging of bladder cancer was demonstrated for 88.9% in 2D US and for 100% in 3D US. 3D volumetric reconstructed US is a non-invasive and accurate technique for tumor detection of bladder cancer.

Magnetic resonance imaging of breast cancer and correlation with prognostic factors.

BACKGROUND: Prognostic factors of breast cancer have been used for the prediction of clinical outcome or selection of patients for complementary treatment. Some of the imaging features of breast cancer, e.g. magnetic resonance imaging (MRI), are associated with these prognostic factors. PURPOSE: To evaluate the relationship between dynamic enhanced MR features and prognostic factors of clinical outcome of breast cancer. MATERIAL AND METHODS: A total of 136 patients with 151 breast cancers underwent 1.5T dynamic MR imaging with the use of a dynamic T1-weighted three-dimensional fast low-angle shot (FLASH) subtraction imaging technique. Morphological and kinetic analyses of MR features were evaluated using the American College of Radiology (ACR) Breast Imaging Reporting and Data System (BI-RADS) MRI lexicon. Pathological prognostic factors were correlated with MR imaging characteristics, including tumor size, histological grade, lymph node status, expression of estrogen receptor (ER), expression of progesterone receptor (PR), expression of c-erbB2, determination of Ki-67 index, and microvascular density (MVD), using univariate and multivariate statistical analyses. RESULTS: Based on univariate and multivariate analyses, spiculated tumor margins correlated significantly with lower histological grade (I-II) and positive PR expression. Rim enhancement was significantly correlated with high histological grade, presence of axillary lymph node metastasis, large tumor size, increased Ki-67 index, and increased MVD. Early peak enhancement, as seen on the first scan after contrast medium injection, was correlated with negative ER expression. CONCLUSION: The presence of a lesion with a spiculated margin may predict a relatively good prognosis, and the presence of a lesion with rim enhancement may predict a relatively poor prognosis.

Sonography of the pediatric thyroid: a pictorial essay.

The purpose of this article is to review the various pediatric thyroid diseases using sonographic images. These diseases included congenital hypothyroidism (dysgenesis [aplasia; ectopy; hypoplasia], dyshormonogenesis, transient hypothyroidism), thyroglossal duct cyst, Graves' disease, Hashimoto's thyroiditis, suppurative thyroiditis, nodular hyperplasia (goiter) and thyroid mass. Thyroid sonogram is the primary method used for thyroid disease and can be used for guiding of fine needle aspiration to obtain a more accurate diagnosis for suspected thyroid lesions.

Sonographic differentiation of benign and malignant cystic lesions of the breast.

OBJECTIVE: The purpose of this study was to subdivide the types of sonographic findings of benign versus malignant cystic masses and to determine appropriate patient care according to the sonographic findings with pathologic correlation. METHODS: The sonographic findings of 175 symptomatic cystic breast lesions were pathologically proven and reviewed retrospectively. Cystic lesions were classified as 6 types: simple cysts (type I), clustered cysts (type II), cysts with thin septa (type III), complicated cysts (type IV), cystic masses with a thick wall/septa or nodules (type V), and complex solid and cystic masses (type VI). Sonographic findings were compared with the pathologic results and were evaluated according to the incidence of benign and malignant masses. RESULTS: All 23 type I, 15 type II, 22 type III, and 35 type IV cases were pathologically proven to be benign. Seven (25.9%) of the 27 type V cases and 33 (62.3%) of the 53 type VI cases were proven to be malignant. We analyzed the shapes and margins of 80 cases of cystic masses with a solid component (types V and VI); 16 (44%) of 36 sonographically circumscribed masses were malignant. CONCLUSIONS: Because the sonographically detected simple cysts (type I), clustered cysts (type II), and cysts with thin septa (type III) were all benign, annual routine follow-up appears reasonable. Symptomatic complicated cysts (type IV) should be aspirated and appropriately treated according to clinical symptoms. Cystic masses with a solid component (types V and VI) should be examined by biopsy with pathologic confirmation.

Endovascular management of immediate procedure-related complications of failed hemodialysis access recanalization.

Endovascular procedures are becoming the standard type of care for the management of hemodialysis vascular access dysfunction. As with any type of medical procedure, these techniques can result in procedure-related complications, although the expected number of complications is low. The clinical extent of these complications varies from case to case. Management of these cases depends on the clinical presentation. Major complications such as vein rupture, arterial embolism, remote site bleeding or hematoma, symptomatic pulmonary embolism and puncture site complications necessitating treatment require major therapy. Minor complications such as non-flow compromising small puncture site hematoma or pseudoaneurysms require little or no therapy. It is essential that the interventionist be prepared to manage these complications appropriately when they arise.

Clinical use of renal perfusion imaging by means of harmonic sonography with a microbubble contrast agent in patients after renal transplantation: preliminary study.

OBJECTIVE: The purpose of this research was to determine the feasibility of renal perfusion imaging by means of harmonic sonography with a microbubble contrast agent for the evaluation of renal perfusion after renal transplantation compared with technetium Tc 99m diethylenetriamine pentaacetic acid ((99m)Tc-DTPA) scans. METHODS: During a 10-month period, 100 patients with renal transplantation that included normal perfusion (n=68) and delayed perfusion including chronic rejection (n=19), acute rejection (n=9), arterial stenosis (n=2), and urinary stricture (n=2) underwent sonographic renal perfusion imaging and (99m)Tc-DTPA scans. Sonographic images were obtained every 3 seconds for a total of 3 minutes after administration of a bolus injection of 4 g of the microbubble contrast agent at a concentration of 300 mg/mL. Sonographic renal perfusion images were converted into a renal perfusion curve, and the calculated time at the peak of the curve (T(peak)) was compared with that of the (99m)Tc-DTPA scan. RESULTS: The T(peak) with the (99m)Tc-DTPA scan was 14.9 seconds in the normal group and 33 seconds in the delayed perfusion group. The T(peak) on sonographic renal perfusion images was 25 seconds in the normal group and 44.8 seconds in the delayed perfusion group. Sonographic renal perfusion images showed good correlation with the (99m)Tc-DTPA scan (r=0.74; P=.0001). The cutoff value of the T(peak) on sonographic renal perfusion images was 35 seconds (sensitivity=85%; specificity=90%). CONCLUSIONS: The renal perfusion images obtained by means of harmonic sonography with a microbubble contrast agent constitute an effective sonographic technique for the evaluation of renal perfusion abnormalities after renal transplantation compared with a (99m)Tc-DTPA scan.

Spontaneous intratumoral hemorrhage into hepatocellular carcinoma during transcatheter arterial embolization: a case report.

Spontaneous extrahepatic rupture of hepatocellular carcinoma (HCC) is a rare but serious complication that occurs with an incidence of between 5 and 15% of patients with HCC. It is thought to be preceded by rapid expansion due to intratumoral bleeding. Extrahepatic rupture of HCC has been reported as a rare complication of transcatheter arterial embolization (TAE). Although there have been reports of extrahepatic rupture of HCC after TAE, but there is no report regarding intratumoral hemorrhage into HCC during TAE. We report a unique case of intratumoral hemorrhage into HCC during TAE presumably triggered by TAE. Although a rare complication, intratumoral hemorrhage into HCC after TAE should be considered in any patient with TAE due to HCC.

Neurenteric cyst in the cerebellopontine angle with xanthogranulomatous changes: serial MR findings with pathologic correlation.

We report serial MR findings in a middle-aged woman with a neurenteric cyst involving the cerebellopontine angle cistern with xanthogranulomatous changes. On the initial gadolinium-enhanced T1-weighted MR images, the solid portion of the lesion had homogeneously strong enhancement. Follow-up MR images obtained 6 months later showed that the mass had increased in size; however, the solid portion decreased in size. The enhancing solid portion corresponded to the xanthogranulomatous changes on pathologic correlation.

Spontaneous partial regression of cerebral arteriovenous malformation.

Arteriovenous malformation (AVM) of the brain is one of the important pathologic conditions which cause intracerebral or subarachnoid hemorrhage, epilepsy, or chronic cerebral ischemia. The spontaneous regression of cerebral AVM is reported to be very rare and more likely to occur when the AVM is small, is accompanied by hemorrhage, and has fewer arterial feeders. We report a case of right occipital AVM which at follow-up angiography performed four years later showed near-complete spontaneous regression.