Cerebellar Ataxia With Neuropathy and Vestibular Areflexia Syndrome Due to Replication Factor C Subunit 1 Gene Repeat Expansion.

ABSTRACT: A 56-year-old man was born to consanguineous parents. He experienced slow-progressing sensory disturbances in the upper extremities. T1-weighted images showed cerebellar atrophy. 123I-IMP SPECT revealed reduced cerebral blood flow in the cerebellum. 123I-FP-CIT SPECT showed low uptake of dopamine transporter in the bilateral tail of the striatum. 123I-MIBG scintigraphy shows a decreased heart-to-mediastinum ratio. Flanking polymerase chain reaction suggested biallelic repeat expansion in intron 2 of RFC1, and subsequent repeat-primed polymerase chain reaction revealed ACAGG repeat expansion. Thus, he was diagnosed as cerebellar ataxia with neuropathy and vestibular areflexia syndrome.

Magnetic resonance imaging-based risk factors of hepatocellular carcinoma after direct-acting antiviral therapy: A multicenter observational study.

AIM: To determine risk factors associated with hepatocellular carcinoma (HCC) development following direct-acting antiviral (DAA) therapy. METHODS: We enrolled patients with chronic hepatitis C who underwent direct-acting antiviral therapy and achieved sustained virologic response at 12 weeks between 2012 and 2018. Subsequently, patients were followed up. The primary endpoint was the development of HCC or the date of the last follow up when the absence of HCC was confirmed. Uni- and multivariate Cox proportional hazards models were used to identify factors contributing to HCC development, including gadoxetic acid-enhanced magnetic resonance imaging findings. The cumulative incidence rates of HCC development were calculated using the Kaplan-Meier method, and differences between groups were assessed using the log-rank test. RESULTS: The final study cohort comprised 482 patients (median age 70.5 years; 242 men). The median follow-up period was 36.8 months. Among 482 patients, 96 developed HCC (19.9%). The 1-, 3-, and 5-year cumulative rates of HCC development were 4.9%, 18.6%, and 30.5%, respectively. Multivariate analysis revealed that age, male sex, history of HCC, and hepatobiliary phase hypointense nodules without arterial phase hyperenhancement were independent risk factors significantly associated with HCC development (p < 0.001-0.04). The highest risk group included patients with both a history of HCC and the presence of hepatobiliary phase hypointense nodules without arterial phase hyperenhancement (the 1- and 3-year cumulative HCC development rates were 14.2% and 62.2%, respectively). CONCLUSION: History of HCC and presence of hepatobiliary phase hypointense nodules without arterial phase hyperenhancement were strong risk factors for HCC development following direct-acting antiviral therapy.

Association of the lung immune prognostic index with the survival of patients with idiopathic interstitial pneumonias.

BACKGROUND AND OBJECTIVE: The lung immune prognostic index (LIPI), a simple index calculated from the blood lactate dehydrogenase level and derived neutrophil-to-lymphocyte ratio, is thought to be associated with host immune status. However, the utility of LIPI in patients with idiopathic interstitial pneumonias (IIPs) is unknown. METHODS: In this multicentre, retrospective, observational study, an association between LIPI and the survival of patients with IIPs was evaluated. RESULTS: Exploratory and validation cohorts consisting of 460 and 414 patients with IIPs, respectively, were included (159 and 159 patients had idiopathic pulmonary fibrosis [IPF], and 301 and 255 had non-IPF, respectively). In the exploratory cohort, patients with IPF and a low LIPI had significantly better survival than those with a high LIPI (median of 5.6 years vs. 3.9 years, p = 0.016). The predictive ability of LIPI for the survival of patients with IPF was validated in the validation cohort (median of 8.5 years vs. 4.4 years, p = 0.003). In a multivariate Cox proportional hazard analysis, LIPI was selected as an independent predictive factor for the survival of IPF patients. There was no significant association between LIPI and survival of non-IPF patients in the exploratory and validation cohorts. CONCLUSION: The LIPI was a predictive factor for the survival of patients with IPF and could aid the management of IPF.

Key CT and MRI findings of drug-associated hepatobiliary and pancreatic disorders.

Obtaining an imaging diagnosis of various hepatobiliary and pancreatic disorders caused by certain drugs can often be challenging. Familiarity with these conditions may improve diagnostic accuracy and patient management. This review aimed to describe the imaging findings of drug-associated hepatobiliary and pancreatic disorders and identify suggestions for obtaining a correct diagnosis. We focused on relatively common disorders or those that can present with characteristic imaging findings, such as drug-induced acute hepatitis, sinusoidal obstruction syndrome, focal nodular hyperplasia-like lesions, hepatocellular adenoma, pseudocirrhosis, chemotherapy-associated steatohepatitis, amiodarone deposition in the liver, secondary iron overload, drug-induced pancreatitis, pancreatic enlargement after epoprostenol therapy, ceftriaxone-associated gallbladder pseudolithiasis, immune-related adverse events, and methotrexate-associated lymphoproliferative disorders.

Gadoxetic Acid-Enhanced Liver MRI: Everything You Need to Know.

ABSTRACT: Since its introduction in the worldwide medical market, gadoxetic acid has attracted considerable interest. The year 2023 marks the 15th anniversary of the introduction of gadoxetic acid in Japan. Gadoxetic acid-enhanced magnetic resonance imaging (GA-MRI) is the predominantly performed contrast MRI examination for the liver. Its most essential characteristic, namely, the hepatobiliary phase, revolutionized the clinical management of liver disease. Gadoxetic acid-enhanced MRI is currently the most efficient method for focal liver lesion detection and analysis. Meta-analyses demonstrated its excellent effectiveness for the diagnosis of hepatocellular carcinoma and liver metastases. Owing to the extensive usage of gadoxetic acid, a hepatobiliary phase hypointense nodule without arterial phase hyperenhancement is well documented. The existence of such nodules may be a sign of hypervascular hepatocellular carcinoma in nodules and other areas in the liver. Apart from its role in tumor identification and characterization, GA-MRI can help assess response to therapy and liver fibrosis. Therefore, it is proposed to use gadoxetic acid as the first option for MRI of the liver in the majority of patients. The efficacy of gadoxetic acid surpasses its disadvantages, rendering this contrast agent the preferred choice for routine MRI of the liver. The clinical use of GA-MRI is discussed in this review article.

Six-week oral prednisolone therapy for immune-related pneumonitis: a single-arm phase II study.

BACKGROUND: There has been no prospective trial for treatment of immune-related pneumonitis (irP) occurred after immune checkpoint inhibitors (ICIs). METHODS: In this single-arm phase II study, patients with cancer with grade ≥2 irP received oral prednisolone (1 mg/kg/day), tapered over 6 weeks. The primary endpoint was a pneumonitis control rate at 6 weeks from the start of the study treatment, defined as complete disappearance or partial improvement of irP in high-resolution CT of the chest. RESULTS: Among 57 patients enrolled, 56 were included in the final analysis. The most frequent cause of irP was single ICI therapy (51.8%), followed by combination with chemotherapy plus ICI (39.3%). Thirty-five (62.5%) patients had grade 2 irP and 21 (37.5%) had grade ≥3. Fifty-one (91.1%) patients completed the study treatment while 5 discontinued the study treatment because of relapse of irP (n=1), death from cancer (n=1), occurrence of immune-related hepatitis (n=1), extension of the treatment duration more than 6 weeks (n=1), and attending physician's decision (n=1). Six weeks after the start of the study treatment, 16 (28.5%) patients demonstrated complete recovery from irP, 35 (62.5%) had a partial improvement in irP, 1 (1.8%) had a relapse of irP, and 4 (7.1%) were not evaluable. The pneumonitis control rate at 6 weeks was 91.1% (95% CI, 80.7% to 96.1%). Twelve weeks after the start of the study treatment, 5 (8.9%), 27 (48.2%), and 15 (26.8%) patients demonstrated complete recovery, partial improvement, and relapse, respectively, and 9 (16.1%) were not evaluable. The pneumonitis control rate at 12 weeks was 57.1% (95% CI, 44.1% to 69.2%). During the observation period, 18 (32.1%) patients experienced a relapse of irP, and of those, 17 received re-treatment with corticosteroids. Grade ≥3 adverse events occurred in 10 (17.9%) patients, in which hyperglycemia was most frequent (n=6). There was no treatment-related death. CONCLUSIONS: In this first prospective study for irP, prednisolone at 1 mg/kg/day, tapered over 6 weeks, demonstrated a promising clinical benefit and manageable toxicity, suggesting a potential treatment option for irP. TRIAL REGISTRATION NUMBER: jRCT: 1041190029.

Impact of Radiation Dose on Treatment of Maxillary Cancer With Superselective Intra-arterial Cisplatin With Radiotherapy.

BACKGROUND/AIM: Maxillary sinus cancer is a relatively rare disease, and treatment is still evolving. We compared the efficacy of superselective intra-arterial infusion of high-dose cisplatin (CDDP) with concomitant radiotherapy (RADPLAT) using three-dimensional conformal radiotherapy (3DCRT) or intensity-modulated radiotherapy (IMRT) and analyzed the relationship between the total radiation dose and the treatment outcome in localized maxillary sinus cancer. PATIENTS AND METHODS: We reviewed the cases of 58 patients with localized maxillary sinus cancer treated with RADPLAT at our institution from March 2004 to November 2020. These 58 patients included 34 who received 3DCRT and 24 who received IMRT. RESULTS: The median follow-up period was 38.4 months. The median prescribed dose to the local lesion was 66 Gy in the 3DCRT group and 70 Gy in the IMRT group. CDDP (100-120 mg/m2) was administered once a week for a median of 6 cycles. The 5-year local control rate and overall survival rate were 69.9% and 72.2%, respectively. The patients treated with 70 Gy had a significantly higher local control rate (87.7%) than those treated with 60 Gy or less (41.0%) (p=0.011). No late grade 3 or higher eye disorders except for cataracts developed in the IMRT group, while grade 4 eye disorders occurred in four patients receiving 3DCRT. CONCLUSION: IMRT can escalate radiation dose safely with acceptable toxicities. The total dose may have an impact on the local control rate in RADPLAT.

Clinical Significance of Liver MR Imaging.

MRI is widely used in clinical practice for detecting liver diseases. Since the introduction of gadoxetic acid, MRI has become the most effective modality for the detection and characterization of focal liver lesions. According to previous meta-analyses, the area under the receiver operating characteristic curve (AUROC) was 0.97-0.99 for the diagnosis of small hepatocellular carcinoma (≥ 2 cm) by gadoxetic-acid-enhanced MRI. Moreover, the AUROC for the diagnosis of colorectal liver metastases was significantly high (0.98). Despite gadoxetic acid's drawbacks, its clinical utility outweighs them, making it the contrast agent of choice in routine liver MRIs. Moreover, clinically, liver MRI has become more prevalent for a quantitative assessment. Liver fibrosis can be evaluated using MR elastography; whereas, hepatic steatosis and iron overload can be evaluated using proton density fat fraction, with high accuracy and reproducibility. This article reviewed the usefulness of liver MRI, which can be a comprehensive imaging modality in clinical practice.

Intranodal dynamic contrast-enhanced CT lymphangiography and dynamic contrast-enhanced MR lymphangiography in microminipig.

OBJECTIVES: To evaluate the feasibility and image quality of intranodal dynamic contrast-enhanced CT lymphangiography (DCCTL) and dynamic contrast-enhanced MR lymphangiography (DCMRL) in microminipigs. METHODS: Our institution's committee for animal research and welfare provided approval. Three microminipigs underwent DCCTL and DCMRL after inguinal lymph node injection of 0.1 mL/kg contrast media. Mean CT values on DCCTL and signal intensity (SI) on DCMRL were measured at the venous angle and thoracic duct (TD). The contrast enhancement index (CEI; increase in CT values pre- to post-contrast) and signal intensity ratio (SIR; SI of lymph divided by SI of muscle) were evaluated. The morphologic legibility, visibility, and continuity of lymphatics were qualitatively evaluated using a 4-point scale. Two microminipigs underwent DCCTL and DCMRL after lymphatic disruption and the detectability of lymphatic leakage was evaluated. RESULTS: The CEI peaked at 5-10 min in all microminipigs. The SIR peaked at 2-4 min in two microminipigs and at 4-10 min in one microminipig. The peak CEI and SIR values were 235.6 HU and 4.8 for venous angle, 239.4 HU and 2.1 for upper TD, and 387.3 HU and 2.1 for middle TD. The visibility and continuity of upper-middle TD scores were 4.0 and 3.3-3.7 for DCCTL, and 4.0 and 4.0 for DCMRL. In the injured lymphatic model, both DCCTL and DCMRL demonstrated lymphatic leakage. CONCLUSIONS: DCCTL and DCMRL in a microminipig model enabled excellent visualization of central lymphatic ducts and lymphatic leakage, indicating the research and clinical potential of both modalities. KEY POINTS: • Intranodal dynamic contrast-enhanced computed tomography lymphangiography showed a contrast enhancement peak at 5-10 min in all microminipigs. • Intranodal dynamic contrast-enhanced magnetic resonance lymphangiography showed a contrast enhancement peak at 2-4 min in two microminipigs and at 4-10 min in one microminipig. • Both intranodal dynamic contrast-enhanced computed tomography lymphangiography and dynamic contrast-enhanced magnetic resonance lymphangiography demonstrated the central lymphatic ducts and lymphatic leakage.

A predictive model for acute exacerbation of idiopathic interstitial pneumonias.

BACKGROUND: Acute exacerbation of idiopathic interstitial pneumonias (AE-IIPs) induces permanent pulmonary dysfunction and is potentially lethal. The unpredictable occurrence of AE-IIPs remains an important clinical issue in the management of IIPs. METHODS: In this multicentre, retrospective, observational study, a predictive score for AE-IIPs was designed using clinical factors based on multivariate Fine-Gray analysis in patients with IIPs. RESULTS: Based on multivariate Fine-Gray analysis in an exploratory cohort of 487 patients with IIPs, the predictive score for AE-IIPs was determined as follows: 1 point each was added for honeycombing on high-resolution computed tomography (H), age >75 years (A) and lactate dehydrogenase level >222 U·L-1 (L); the total score ranged from 0 to 3 (HAL score). The HAL score discriminated the risk of AE-IIPs with a C-index of 0.62 (95% CI 0.56-0.67); this discrimination was verified in a validation cohort of 402 patients with IIPs with a C-index of 0.67 (95% CI 0.60-0.73). In a combined cohort, the estimated cumulative risks for AE-IIPs at 1, 2, 3, 5 and 10 years were 1.9%, 3.5%, 5.1%, 7.7% and 12.9%, respectively, in the total score 0 group; 4.7%, 8.3%, 12.0%, 17.7% and 28.4%, respectively, in the total score 1 group; and 8.0%, 14.2%, 19.7%, 28.7% and 43.0%, respectively, in the total score ≥2 group. Subgroup analysis revealed that the HAL score was applicable to patients with and without idiopathic pulmonary fibrosis. CONCLUSIONS: The HAL score discriminated the risk of AE-IIPs and could aid in the management of IIPs.

Diagnostic value of heart-to-mediastinum ratio in 99mTc-pyrophospate SPECT/CT for transthyretin cardiac amyloidosis.

BACKGROUND: In transthyretin cardiac amyloidosis (ATTR-CA), 99mTc-pyrophosphate myocardial scintigraphy (99mTc-PYP) is a diagnostic tool that utilizes visual and quantitative evaluation. However, false positive cases can occur because of tracer accumulation in the blood. We investigated the effectiveness of the heart-to-mediastinum (H/M) ratio of 99mTc-PYP in ATTR-CA diagnosis. METHODS: We retrospectively included 164 patients who underwent 99mTc-PYP single-photon emission computed tomography/computed tomography between March 2019 and January 2022. The diagnostic accuracy of ATTR-CA was examined by the heart-to-contralateral lung (H/CL) and H/M ratio calculated at 3 hours post-tracer administration. RESULTS: After the exclusion of patients who did not undergo endomyocardial biopsy, 30 patients (15 each with ATTR-CA and without ATTR-CA) were included. The receiver operating characteristic curve used to distinguish ATTR-CA from non-ATTR-CA patients revealed an area under the curve of 0.986 and 0.943, respectively. A H/M ratio of > 1.41 identified ATTR-CA patients with a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 100, 93.3, 93.3, and 100%, respectively. Conversely, an H/CL ratio of > 1.3 identified ATTR-CA patients with 100% sensitivity, 40.0% specificity, 62.5% PPV, and 100% NPV. CONCLUSION: The H/M ratio obtained at 3 hours post-injection has the potential to be a novel indicator for ATTR-CA.

Anterior superior pancreaticoduodenal artery pseudoaneurysm after distal pancreatectomy with en bloc celiac axis resection successfully treated with balloon-assisted coil embolization.

Bleeding is a fatal complication after pancreatectomy. Although coil embolization is a widely accepted treatment option, ischemia of the remaining organs should be prevented. This study reports the successful treatment of intra-abdominal hemorrhage following distal pancreatectomy with en bloc celiac axis resection (DP-CAR) using balloon-assisted coil embolization (BACE). A 59-year-old man was diagnosed with locally advanced pancreatic cancer. The tumor involves the common hepatic artery, splenic artery, and celiac artery. After four cycles of treatment with gemcitabine/nab-paclitaxel, the soft-density masses, surrounding the artery, shrunk. DP-CAR and R0 resections were performed. A minor postoperative pancreatic fistula occurred. Six months postoperatively, the computed tomography showed delayed asymptomatic bleeding from an anterior superior pancreaticoduodenal artery (ASPDA) pseudoaneurysm located near the gastroduodenal artery confluence. BACE was performed by placing a microballoon catheter in the region of confluence of the ASPDA and posterior superior pancreaticoduodenal artery (PSPDA) to prevent coil migration. After inserting the microballoon catheter, coil embolization was performed in the ASPDA. Hepatic blood flow was maintained from the PSPDA. BACE is a useful technique to preserve blood flow to the remnant organs when performing coil embolization for bleeding following a distal pancreatectomy, especially following a DP-CAR.

Water and lipid content of breast tissue measured by six-wavelength time-domain diffuse optical spectroscopy.

Significance: The water and lipid content of normal breast tissue showed mammary gland characteristics with less influence from the chest wall using six-wavelength time-domain diffuse optical spectroscopy (TD-DOS) in a reflectance geometry. Aim: To determine the depth sensitivity of a six-wavelength TD-DOS system and evaluate whether the optical parameters in normal breast tissue can distinguish dense breasts from non-dense breasts. Approach: Measurements were performed in normal breast tissue of 37 breast cancer patients. We employed a six-wavelength TD-DOS system to measure the water and lipid content in addition to the hemoglobin concentration. The breast density in mammography and optical parameters were then compared. Results: The depth sensitivity of the system for water and lipid content was estimated to be ∼15 mm. Our findings suggest that the influence of the chest wall on the water content is weaker than that on the total hemoglobin concentration. In data with evaluation conditions, the water content was significantly higher (p < 0.001) and the lipid content was significantly lower (p < 0.001) in dense breast tissue. The water and lipid content exhibited a high sensitivity and specificity to distinguish dense from non-dense breasts in receiver-operating-characteristic curve analysis. Conclusions: With less influence from the chest wall, the water and lipid content of normal breast tissue measured by a reflectance six-wavelength TD-DOS system, together with ultrasonography, can be applied to distinguish dense from non-dense breasts.

Safety and feasibility of radiofrequency ablation using bipolar electrodes for aldosterone-producing adenoma: a multicentric prospective clinical study.

Evaluation of feasibility and safety of percutaneous radiofrequency ablation using bipolar radiofrequency devices in a prospective multicenter cohort of patients with benign aldosterone-producing adenoma. A total of five institutions participated. CT-guided percutaneous RFA was performed for patients diagnosed as APA. The safety of the procedure was evaluated using the Common Terminology Criteria for Adverse Events. During the 84-day follow-up period, serial changes in plasma aldosterone concentration and plasma renin activity were measured. The percentage of patients with normalized hormonal activity after the procedure, was calculated with 95% confidence intervals. Forty patients were enrolled, and two patients were excluded for cerebral hemorrhage and no safe puncture root. In another patients, RFA was tried, but an intraprocedural intercostal arterial injury occurred. Consequently, RFA was completed in thirty-seven patients (20 men, 17 women; mean age, 50.4 ± 10.0 year). The tumor size was 14.8 ± 3.8 mm. The treatment success rate of the ablation was 94.6% (35/37), and a 2nd session was performed in 2.7% (1/37) patients. Grade 4 adverse events were observed in 4 out of 38 sessions (10.5%). The normalization of plasma aldosterone concentration or aldosterone-renin ratio was 86.5% (72.0-94.1: 95% confidence interval) on day 84. Percutaneous CT-guided RFA for APA using a bipolar radiofrequency system was safe and feasible with clinical success rate of 86.5% on day 84.

Radiological Arterial Anatomy in Mature Microminipigs as a Pre-clinical Research Model in Interventional Radiology.

PURPOSE: To define the radiological arterial anatomy in mature microminipigs as a pre-clinical research animal model in interventional radiology. MATERIALS AND METHODS: Five female microminipigs (weighing 20.9 ± 2.9 kg) were used in this study. Under general anesthesia, computed tomography (CT) angiography was performed using a 16-slice CT scanner. CT was performed 12 s after initiation of an intravenous injection of 40 ml of nonionic contrast media at 3.0 ml/second using a power injector. The transverse CT angiography images were evaluated using a digital imaging and communication in medicine viewer, and the diameters of the following 41 arteries were measured.: ascending aorta, descending aorta, thoracoabdominal aorta, abdominal aorta, pulmonary artery trunk, both pulmonary, brachiocephalic artery, short common bicarotid, both common carotid artery, subclavian, bronchial, internal mammary, celiac, common hepatic, left lateral hepatic, middle hepatic, left hepatic, gastroduodenal, cranial duodenopancreatic, splenic, left gastric, cranial mesenteric, ileocolic , bilateral colic artery, caudal mesenteric, cranial rectal, renal, both external iliac arteries, internal iliac common trunk, and both internal iliac and femoral arteries. RESULTS: The microminipigs' vascular anatomy was the same as domestic pig anatomy and similar to human anatomy. The diameter of the aorta (ascending to abdominal) was 17.1-7.0 mm, iliac and femoral arteries (internal iliac common trunk to femoral artery): 5.5-3.8 mm, pulmonary arteries: 9.3-14.7 mm, and major first aortic branches (e.g., celiac or brachiocephalic artery): 2.2-9.2 mm. CONCLUSION: This study defined the microminipig arterial anatomy in the trunk.

MRI-based radiomics analysis for differentiating phyllodes tumors of the breast from fibroadenomas.

OBJECTIVES: To evaluate the diagnostic performance of MRI-based radiomics model for differentiating phyllodes tumors of the breast from fibroadenomas. METHODS: This retrospective study included 88 patients (32 with phyllodes tumors and 56 with fibroadenomas) who underwent MRI. Radiomic features were extracted from T2-weighted image, pre-contrast T1-weighted image, and the first-phase and late-phase dynamic contrast-enhanced MRIs. To create stable machine learning models and balanced classes, data augmentation was performed. A least absolute shrinkage and selection operator (LASSO) regression was performed to select features and build the radiomics model. A radiological model was constructed from conventional MRI features evaluated by radiologists. A combined model was constructed using both radiomics features and radiological features. Machine learning classifications were done using support vector machine, extreme gradient boosting, and random forest. The area under the receiver operating characteristic (ROC) curve (AUC) was computed to assess the performance of each model. RESULTS: Among 1070 features, the LASSO logistic regression selected 35 features. Among three machine learning classifiers, support vector machine had the best performance. Compared to the radiological model (AUC: 0.77 ± 0.11), the radiomics model (AUC: 0.96 ± 0.04) and combined model (0.97 ± 0.03) had significantly improved AUC values (both p < 0.01) in the validation set. The combined model had a relatively higher AUC than that of the radiomics model in the validation set, but this was not significantly different (p = 0.391). CONCLUSIONS: Radiomics analysis based on MRI showed promise for discriminating phyllodes tumors from fibroadenomas. KEY POINTS: • The radiomics model and the combined model were superior to the radiological model for differentiating phyllodes tumors from fibroadenomas. • The SVM classifier performed best in the current study. • MRI-based radiomics model could help accurately differentiate phyllodes tumors from fibroadenomas.

Fatal pancreatic fistula after laparoscopic distal pancreatectomy for intraductal papillary mucinous carcinoma with pancreaticobiliary maljunction and sphincterotomized papilla: a case report.

BACKGROUND: Pancreatic juice is constantly activated by contaminated bile in patients with pancreaticobiliary maljunction (PBM). Here, we report a case of laparoscopic distal pancreatectomy for a patient with PBM and sphincterotomized papilla, resulting in fatal pancreatic fistula. CASE PRESENTATION: A 79-year-old man was diagnosed with pancreatic intraductal papillary mucinous neoplasm and common bile duct stones. Endoscopic sphincterotomy was performed prior to surgery. The pancreatic duct was simultaneously visualized when the contrast agent was injected into the common bile duct. Sudden bleeding was observed from the abdominal drain on postoperative day (POD) 6. Emergent stent graft placement and coil embolization were performed for bleeding from the splenic artery. On POD 9, the drainage fluid changed to yellowish in color with bile contamination. For internal drainage of the digestive fluid, endoscopic retrograde biliary tube and pancreatic drainage tube were placed. On POD 24, second emergent coil embolization was performed for bleeding from the left gastric artery. On POD 25, open abdominal drainage was performed. On POD 32, third emergent coil embolization was performed for bleeding from the gastroduodenal artery. Subsequently, remnant pancreatic resection was performed. On POD 39, massive bleeding was again observed from the abdominal drain. Emergency arterial portography revealed bleeding in the right wall of the superior mesenteric vein. The patient died of hemorrhagic shock on the same day. CONCLUSIONS: The extreme risk of severe pancreatic fistula after distal pancreatectomy should be considered in patients with PBM and sphincterotomized papilla. In this extraordinary situation, surgeons should promptly decide whether to resect the remnant pancreas to prevent losing the patient.

Consensus report from the 9th International Forum for Liver Magnetic Resonance Imaging: applications of gadoxetic acid-enhanced imaging.

OBJECTIVES: The 9th International Forum for Liver Magnetic Resonance Imaging (MRI) was held in Singapore in September 2019, bringing together radiologists and allied specialists to discuss the latest developments in and formulate consensus statements for liver MRI, including the applications of gadoxetic acid-enhanced imaging. METHODS: As at previous Liver Forums, the meeting was held over 2 days. Presentations by the faculty on days 1 and 2 and breakout group discussions on day 1 were followed by delegate voting on consensus statements presented on day 2. Presentations and discussions centered on two main meeting themes relating to the use of gadoxetic acid-enhanced MRI in primary liver cancer and metastatic liver disease. RESULTS AND CONCLUSIONS: Gadoxetic acid-enhanced MRI offers the ability to monitor response to systemic therapy and to assist in pre-surgical/pre-interventional planning in liver metastases. In hepatocellular carcinoma, gadoxetic acid-enhanced MRI provides precise staging information for accurate treatment decision-making and follow-up post therapy. Gadoxetic acid-enhanced MRI also has potential, currently investigational, indications for the functional assessment of the liver and the biliary system. Additional voting sessions at the Liver Forum debated the role of multidisciplinary care in the management of patients with liver disease, evidence to support the use of abbreviated imaging protocols, and the importance of standardizing nomenclature in international guidelines in order to increase the sharing of scientific data and improve the communication between centers. KEY POINTS: • Gadoxetic acid-enhanced MRI is the preferred imaging method for pre-surgical or pre-interventional planning for liver metastases after systemic therapy. • Gadoxetic acid-enhanced MRI provides accurate staging of HCC before and after treatment with locoregional/biologic therapies. • Abbreviated protocols for gadoxetic acid-enhanced MRI offer potential time and cost savings, but more evidence is necessary. The use of gadoxetic acid-enhanced MRI for the assessment of liver and biliary function is under active investigation.