C-Arm Computed Tomographic Image Fusion for Repetitive Transarterial Chemoembolization of Hepatocellular Carcinoma.

OBJECTIVE: The aim of this study was to evaluate the potential implications of fusion imaging with C-arm computed tomography (CACT) scans for repetitive conventional transarterial chemoembolization (cTACE) for hepatocellular carcinoma. MATERIALS AND METHODS: Fifty-six cTACE sessions were performed using fusion CACT images from September 2020 to June 2021 in a tertiary referral center, and the data were retrospectively analyzed. Fusion of unenhanced and enhanced CACT images was considered when previously accumulated iodized oil hampered the identification of local tumor progression or intrahepatic distant metastasis (indication A), when a tumor was supplied by multiple arteries with different origins from the aorta and missing tumor enhancement was suspected (indication B), or when iodized oil distribution on immediate post-cTACE CACT images needed to be precisely compared with the pre-cTACE images (indication C). Fusion image quality, initial tumor response, time to local progression (TTLP) of index tumors, and time to progression (TTP) were evaluated. RESULTS: The fusion quality was satisfactory with a mean misregistration distance of 1.4 mm. For the 40 patients with indication A, the initial tumor responses at 3 months were nonviable, equivocal, and viable in 27 (67.5%), 4 (10.0%), and 9 (22.5%) index tumors, respectively. The median TTLP and TTP were 14.8 months and 4.5 months, respectively. For 10 patients with indication B, the median TTLP and TTP were 8.3 months and 2.6 months, respectively. Among the 6 patients with indication C, 2 patients were additionally treated at the same cTACE session after confirming incomplete iodized oil uptake on fusion imaging. CONCLUSIONS: Fusion CACT images are useful in patients with hepatocellular carcinoma undergoing repetitive cTACE.

Transcatheter arterial embolization of cystic artery bleeding.

Purpose: The purpose of this study is to assess the safety and clinical outcomes of transcatheter arterial embolization (TAE) via the cystic artery for treating patients with bleeding from the cystic artery. Materials and Methods: This retrospective study included 20 patients who underwent TAE via the cystic artery between January 2010 and May 2022. Radiological images and clinical data were reviewed to evaluate causes of bleeding, procedure-related complications, and clinical outcomes. Technical success was defined as the disappearance of contrast media extravasation or pseudoaneurysm, as demonstrated on completion angiography. Clinical success was defined as discharge from the hospital without any bleeding-related issues. Results: Hemorrhagic cholecystitis (n = 10) was the most common cause of bleeding, followed by iatrogenic (n = 4), duodenal ulcer (n = 3), tumor (n = 2), and trauma (n = 1). Technical success was achieved in all cases, and clinical success was achieved in 70% (n = 14) of patients. Three patients developed ischemic cholecystitis as a complication. Six patients with clinical failure died within 45 days after embolization. Conclusion: TAE through the cystic artery has a high technical success rate in treating cystic artery bleeding, but clinical failure remains a common occurrence due to concurrent medical conditions and the development of ischemic cholecystitis.

The spectrum of imaging manifestations of Gorham-Stout disease: a novel dynamic contrast-enhanced MR lymphangiography.

BACKGROUND: To describe the radiological features of Gorham-Stout disease (GSD) as evaluated using plain radiography and dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) imaging techniques. METHODS: Clinical and conventional imaging data were retrospectively reviewed for 15 patients with GSD between January 2001 and December 2020. After December 2018, DCMRL examinations were performed for lymphatic vessel evaluation in patients with GSD and reviewed in four patients. RESULTS: The median age at diagnosis was 9 years (range: 2 months-53 years). The clinical manifestations were dyspnea in seven patients (46.7%), sepsis in 12 (80.0%), orthopedic problems in seven (46.7%), and bloody chylothorax in seven (46.7%). The common sites of osseous involvement were the spine (73.3%) and pelvic bone (60.0%). Among the non-osseous involvements, peri-osseous infiltrative soft-tissue abnormalities adjacent to the area of bone involvement were the most common (86.7%), followed by splenic cysts (26.7%) and interstitial thickening (26.7%). DCMRL demonstrated weak central conducting lymphatic flow in two patients with abnormal giant tortuous thoracic ducts and no flow in one patient. All patients who underwent DCMRL in this study presented with altered anatomical lymphatics and functional flow with collateralization. CONCLUSION: DCMRL imaging and plain radiography are very useful for determining the extent of GSD. DCMRL is a novel imaging tool for the visualization of abnormal lymphatics in patients with GSD, which helps in further treatment. Therefore, in patients with GSD, it might be necessary to obtain not only plain radiographs but also MR and DCMRL images.

Clinical course and role of embolization in patients with spontaneous rupture of hepatocellular carcinoma.

Background: A diverse clinical course after the spontaneous rupture of hepatocellular carcinoma (HCC) renders nonstandardized treatment protocols. Purpose: To evaluate clinical course and role of transcatheter arterial embolization (TAE) in patients with rupture of HCC. Materials and methods: This retrospective study included 127 patients who were treated for ruptured HCC at single institution between 2005 and 2014. After multidisciplinary discussion, patients underwent medical management, TAE, emergency surgery or staged surgery. Patients were retrospectively divided into two groups based on the intent of treatment: curative and palliative. The rebleeding rate and 1-month and overall survival (OS) were compared between two groups. The incidence and survival of patients with intraperitoneal drop metastasis (IPDM) were also analyzed. Results: The overall rebleeding rate in patients who underwent TAE was 3.1% (3/96). One-month mortality rate was 6.3% (8/127). The rebleeding and 1-month mortality rates were not significantly different between two groups. OS was significantly higher in the curative treatment group (median: 12.0 vs 2.2 months, p<0.001). Among 96 patients who initially received TAE, ten patients underwent staged operation (10.4%). The median OS for medical management, TAE, emergency surgery and staged surgery was 2.8, 8.7, 19.1 and 71.1 months, respectively. Of all patients, 15.2% developed IPDM mostly within 1 year and their survival was poorer than that of patients without IPDM (median: 6.3 vs. 15.1 months, p<0.001). Conclusion: TAE provided effective immediate hemostasis with a low rebleeding rate and may serve as a bridge to elective surgery. IPDM frequently occurred within 1 year and manifested poor survival; thus, close surveillance should be considered for patients with spontaneous rupture of HCC.

Thoracic duct embolization in treating postoperative chylothorax: does bail-out retrograde access improve outcomes?

OBJECTIVES: To evaluate clinical outcomes of thoracic duct embolization (TDE) for the management of postoperative chylothorax with the aid of the bail-out retrograde approach for thoracic duct cannulation (TDC). MATERIALS AND METHODS: Forty-five patients with postoperative chylothorax underwent Lipiodol lymphangiography (LLG) between February 2016 and November 2019. If targetable central lymphatic vessels were identified in LLG, TDC, a prerequisite for TDE, was attempted. While the conventional antegrade transabdominal approach was the standard TDC method, the retrograde approach was applied as a bail-out method. Embolization, the last step of TDE, was performed after confirming leakages in the trans-TDC catheter lymphangiography. Technical and clinical success rates were determined retrospectively. RESULTS: TDC was attempted in 40 among 45 patients based on LLG findings. The technical success rate of TDC with the conventional antegrade approach was 78% (31/40). In addition, six more patients were cannulated using the bail-out retrograde approach, which raised the technical success rate to 93% (37/40). While 35 patients underwent embolization (TDE group), ten patients did not (non-TDE group) for the following reasons: (1) lack of targetable lymphatics for TDC in LLG (n = 5), (2) technical failure of TDC (n = 3), and (3) lack of discernible leakages in the transcatheter lymphangiography (n = 2). The clinical success of the TDE group was 89% (31/35), compared with 50% (5/10) of the non-TDE group. One major procedure-related complication was bile peritonitis caused by the needle passage of the distended gallbladder. CONCLUSIONS: Bail-out retrograde approach for TDC could improve the overall technical success of TDC significantly. KEY POINTS: • Bail-out retrograde thoracic duct access may improve the overall technical success of thoracic duct access, thus improving the clinical success of thoracic duct embolization.

Metformin Derivative HL156A Reverses Multidrug Resistance by Inhibiting HOXC6/ERK1/2 Signaling in Multidrug-Resistant Human Cancer Cells.

Multidrug resistance is a significant clinical crisis in cancer treatment and has been linked to the cellular expression of multidrug efflux transporters. The aim of this study was to examine the effects and mechanisms of the metformin derivative HL156A on human multidrug resistance (MDR) cancer cells. Here, HL156A significantly suppressed cell growth and colony formation through G2/M phase cell cycle arrest in MDR cancer cells. HL156A also reduced the wound closure rate and cell migration and induced caspase-3-dependent apoptosis. We found that HL156A inhibited the expression of MDR1 by inhibiting the HOXC6-mediated ERK1/2 signaling pathway and increased the sensitivity to paclitaxel or doxorubicin in MDR cells. Furthermore, HL156A significantly inhibited angiogenesis in a chicken chorioallantoic membrane (CAM) assay. These results suggest the potential of the metformin derivative HL156A as a candidate therapeutic modality for the treatment of human multidrug-resistant cancers.

Deep Learning for Chest Radiograph Diagnosis in the Emergency Department.

BackgroundThe performance of a deep learning (DL) algorithm should be validated in actual clinical situations, before its clinical implementation.PurposeTo evaluate the performance of a DL algorithm for identifying chest radiographs with clinically relevant abnormalities in the emergency department (ED) setting.Materials and MethodsThis single-center retrospective study included consecutive patients who visited the ED and underwent initial chest radiography between January 1 and March 31, 2017. Chest radiographs were analyzed with a commercially available DL algorithm. The performance of the algorithm was evaluated by determining the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity at predefined operating cutoffs (high-sensitivity and high-specificity cutoffs). The sensitivities and specificities of the algorithm were compared with those of the on-call radiology residents who interpreted the chest radiographs in the actual practice by using McNemar tests. If there were discordant findings between the algorithm and resident, the residents reinterpreted the chest radiographs by using the algorithm's output.ResultsA total of 1135 patients (mean age, 53 years ± 18; 582 men) were evaluated. In the identification of abnormal chest radiographs, the algorithm showed an AUC of 0.95 (95% confidence interval [CI]: 0.93, 0.96), a sensitivity of 88.7% (227 of 256 radiographs; 95% CI: 84.1%, 92.3%), and a specificity of 69.6% (612 of 879 radiographs; 95% CI: 66.5%, 72.7%) at the high-sensitivity cutoff and a sensitivity of 81.6% (209 of 256 radiographs; 95% CI: 76.3%, 86.2%) and specificity of 90.3% (794 of 879 radiographs; 95% CI: 88.2%, 92.2%) at the high-specificity cutoff. Radiology residents showed lower sensitivity (65.6% [168 of 256 radiographs; 95% CI: 59.5%, 71.4%], P < .001) and higher specificity (98.1% [862 of 879 radiographs; 95% CI: 96.9%, 98.9%], P < .001) compared with the algorithm. After reinterpretation of chest radiographs with use of the algorithm's outputs, the sensitivity of the residents improved (73.4% [188 of 256 radiographs; 95% CI: 68.0%, 78.8%], P = .003), whereas specificity was reduced (94.3% [829 of 879 radiographs; 95% CI: 92.8%, 95.8%], P < .001).ConclusionA deep learning algorithm used with emergency department chest radiographs showed diagnostic performance for identifying clinically relevant abnormalities and helped improve the sensitivity of radiology residents' evaluation.Published under a CC BY 4.0 license.Online supplemental material is available for this article.See also the editorial by Munera and Infante in this issue.

Gastrointestinal tract complications after hepatic radiofrequency ablation: CT prediction for major complications.

PURPOSE: To analyze CT features that predict major gastrointestinal tract (GIT) complication after hepatic radiofrequency ablation (RFA). MATERIALS AND METHODS: Of 3933 patients who underwent RFA for hepatic malignancy from January 2005 to September 2016, 52 patients (1.32%) who had GIT complications were retrospectively enrolled. Electronic medical records and CT results were reviewed for location (left vs. right lobe, subcapsular vs. non-subcapsular) and tumor size, distance from the hepatic capsule, number and length of needles, ablation time, presence of artificial ascites, previous history of percutaneous treatment or operation, injured organs, length and thickness of injured GIT, presence of adjacent infiltration, ascites, mucosal discontinuity, and free air, and eccentricity. Patients were divided into those that recovered with conservative treatment (minor group) and those that required operation (major group). Chi-square test, Fisher's exact test, and Mann-Whitney U test analyzed differences between the two groups; however, the most significant variable was found using binary logistic regression analysis. RESULTS: Of 52 patients who had GIT complications after hepatic RFA, 2 patients (0.05%) had major GIT complications, while the remaining 50 patients (1.27%) had minor complications. Most (47/52, 90.4%) of the tumors were located at subcapsular portion. 66% of tumors were located at the left hepatic lobe. Stomach was the most frequent injured organ (28/52, 53.8%), followed by colon (17/52, 32.7%) and small bowel (7/52, 13.5%). Patients with major GIT complications had significantly thicker (1.8 vs. 1.1 cm) and concentric (2/2, 100% vs. 1/50, 2.0%) bowel wall thickening with mucosal discontinuity (2/2, 100% vs. 0/50, 0%) than those with minor complications (P < 0.05). CONCLUSION: GIT complication after hepatic RFA is rare and often requires conservative treatment. However, patients who show >1.65-cm-thick, concentric bowel wall thickening with mucosal disruption on CT after hepatic RFA may have major GIT injury that requires bowel surgery.

New metformin derivative HL156A prevents oral cancer progression by inhibiting the insulin-like growth factor/AKT/mammalian target of rapamycin pathways.

Metformin is a biguanide widely prescribed as an antidiabetic drug for type 2 diabetes mellitus patients. The purpose of the present study was to observe the effects of the new metformin derivative, HL156A, on human oral cancer cell and to investigate its possible mechanisms. It was observed that HL156A significantly decreased FaDu and YD-10B cell viability and colony formation in a dose-dependent way. HL156A also markedly reduced wound closure and migration of FaDu and YD-10B cells. We observed that HL156A decreased mitochondrial membrane potential and induced reactive oxygen species (ROS) levels and apoptotic cells with caspase-3 and -9 activation. HL156A inhibited the expression and activation of insulin-like growth factor (IGF)-1 and its downstream proteins, AKT, mammalian target of rapamycin (mTOR), and ERK1/2. In addition, HL156A activated AMP-activated protein kinase/nuclear factor kappa B (AMPK-NF-κB) signaling of FaDu and YD-10B cells. A xenograft mouse model further showed that HL156A suppressed AT84 mouse oral tumor growth, accompanied by down-regulated p-IGF-1, p-mTOR, proliferating cell nuclear antigen (PCNA) and promoted p-AMPK and TUNEL expression. These results suggest the potential value of the new metformin derivative HL156A as a candidate for a therapeutic modality for the treatment of oral cancer.