Comparison of three obturator nerve block techniques for injectate spread into the obturator canal: a randomized controlled trial.

PURPOSE: The obturator nerve branches into the obturator canal; therefore, local anesthetic spread into the obturator canal predicts the success of the obturator nerve block (ONB). We compared three ONB techniques for the spread of local anesthetic mixed with contrast medium into the obturator canal. METHODS: We performed the ONB using the classical pubic approach (PA), inguinal approach (IA), or ultrasound-guided methodologic approach (UMA) in 143 patients undergoing transurethral resection of bladder tumors. The obturator nerve course and branching patterns of the UMA group were examined using ultrasound imaging. After injecting a local anesthetic mixed with a contrast medium, we evaluated its spread into the obturator canal using fluoroscopic imaging. P < 0.05 indicated statistical significance. RESULTS: Success rate of obturator canal enhancement was the greatest in the UMA group (84%; P < 0.001); the PA (42.6%; 20/47 patients) and IA (47.8%; 22/46 patients) groups did not differ significantly (P = 1.000). Both branches of the obturator nerve passed above the superior margin of the external obturator muscle (EOM), and the obturator canal was enhanced in 13 of 50 (26%) patients in the UMA group. The posterior branch of the obturator nerve passed between the superior and main fasciculi of the EOM in 37 of 50 patients (74%) in the UMA group; the obturator canal was enhanced in 29 of these 37 patients (78%). CONCLUSION: Local anesthetic spread into the obturator canal using the UMA was superior to that using the PA and IA. Both branches of the obturator nerve could be blocked using the UMA.

Cardiac Sarcoidosis Concomitant with Large-vessel Aortitis Detected by 18F-fluorodeoxyglucose Positron Emission Tomography.

We herein report a case of concurrent cardiac sarcoidosis and large-vessel aortitis detected by 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) and followed up during immunosuppressive therapy. After high-dose prednisolone administration (1 mg/kg), serial FDG-PET showed that almost all of the abnormal FDG uptake in the heart and extracardiac region, including the abdominal to bilateral iliac arteries, had been disappeared. During the tapering of prednisolone, additive methotrexate therapy was needed to treat the recurrence of cardiac sarcoidosis. FDG-PET is a useful tool for detecting cardiac sarcoidosis concomitant with large-vessel aortitis and monitoring the effectiveness of immunosuppressive therapy.

Periportal lymphatic system on post-hepatobiliary phase Gd-EOB-DTPA-enhanced MR imaging in normal subjects and patients with chronic hepatitis C.

PURPOSE: We sought to evaluate visualization of periportal lymphatics and lymph nodes (lymphatic system) on Gd-EOB-DTPA-enhanced magnetic resonance (MR) images using a fat-suppressed T2-weighted sequence with 3-dimensional (3D) volume isotropic turbo spin echo acquisition (VISTA) at 3.0 T in normal subjects and patients with chronic hepatitis C. METHODS: MR imaging was performed in 254 subjects between June 2013 and May 2016. After applying inclusion and exclusion criteria, the final population was 31 normal subjects and 34 patients with chronic hepatitis C. Images were acquired after the hepatobiliary phase following intravenous administration of Gd-EOB-DTPA, which causes signal loss in the bile ducts, to facilitate the visualization of the periportal lymphatic system. Two radiologists assessed the visualization of the periportal lymphatic system in 31 normal subjects. The axial dimensions of the main periportal lymphatic system in normal subjects were measured and compared with those of 34 patients with chronic hepatitis C using the Mann-Whitney U-test, and their correlation with a hepatic fibrosis marker, the Fibrosis-4 (FIB-4), was assessed using Spearman's rank correlation test. RESULTS: The periportal lymphatic system was detected as high signal intensity areas surrounding the portal vein up to the third branches by each reader in all normal subjects. The axial dimensions of the main periportal lymphatic system in patients with chronic hepatitis C were significantly larger than those in normal subjects (p < 0.0001), and showed a significantly positive correlation with the FIB-4 score (ρ = 0.73, p < 0.001). CONCLUSIONS: Fat-suppressed T2-weighted MR imaging with 3D-VISTA acquired after the hepatobiliary phase on Gd-EOB-DTPA-enhanced imaging may be a useful noninvasive method for evaluating the periportal lymphatic system and the degree of hepatic fibrosis.

Perirenal lymphatic systems: Evaluation using spectral presaturation with inversion recovery T2 -weighted MR images with 3D volume isotropic turbo spin-echo acquisition at 3.0T.

PURPOSE: To evaluate the normal anatomy of the perirenal lymphatics using spectral presaturation with inversion recovery (SPIR) T2 -weighted magnetic resonance imaging (MRI) with 3D volume isotropic turbo spin-echo acquisition (VISTA) at 3.0T. MATERIALS AND METHODS: This retrospective study was approved by the two Institutional Review Boards and informed consent was waived. Thin-collimated axial images obtained using SPIR T2 -weighted MR imaging sequences with 3D VISTA at 3.0T from 50 patients (100 kidneys) with normal renal function were retrospectively reviewed. The perirenal lymphatic vessels were defined as fluid signal intensity structures on this MRI sequence. Two readers independently assessed the degree of visualization of the perirenal lymphatics using a 4-point scale in four anatomical regions, including the renal hilar, capsular, communicating pericapsular, and subfascial lymphatics, and interobserver agreement was evaluated with weighted kappa statics. The detectability of each lymphatic system was calculated for each reader using confidence level ratings of grades 1 and 2 as positive and grades 3 and 4 as negative. RESULTS: Interobserver agreement for the visualization grades was almost perfect (kappa value = 0.9). The renal hilar lymphatics along the renal vein were clearly identified in all patients. The detectability of other perirenal lymphatics was 44% for the capsular lymphatics, 39% for communicating pericapsular lymphatics, and 22% for the subfascial lymphatics. There was no laterality regarding the detectability of the perirenal lymphatics. CONCLUSION: The findings of this study support the feasibility of SPIR T2 -weighted MR images with 3D-VISTA at 3.0T for evaluating the perirenal lymphatic systems. J. MAGN. RESON. IMAGING 2016;44:897-905.

A clinical approach to brown adipose tissue in the para-aortic area of the human thorax.

BACKGROUND: Human thoracic brown adipose tissue (BAT), composed of several subdivisions, is a well-known target organ of many clinical studies; however, the functional contribution of each part of human thoracic BAT remains unknown. The present study analyzed the significance of each part of human thoracic BAT in the association between regional distribution, cellularity, and factors involved in the functional regulation of thoracic BAT. METHODS: We analyzed 1550 healthy adults who underwent medical check-ups by positron-emission tomography and computed tomography (PET-CT) imaging, 8 cadavers, and 78 autopsy cases in an observational study. We first characterized the difference between the mediastinum and the supraclavicular areas using counts of BAT detection and conditions based on PET-CT outcomes. The measurable important area was then subjected to systematic anatomical and immunohistochemical analyses using anti-uncoupling protein 1 (UCP1) antibody to characterize the cellularity in association with age and sex. RESULTS: In PET-CT scanning, the main site of thoracic BAT was the mediastinum rather than the supraclavicular area (P < 0.05). Systemic macroanatomy revealed that the thumb-sized BAT in the posterior mediastinal descending para-aortic area (paBAT) had feeding vessels from the posterior intercostal arteries and veins and sympathetic/parasympathetic innervation from trunks of the sympathetic and vagus nerves, respectively. Immunohistochemical analysis indicated that the paBAT exhibited immunoreactivity for tyrosine hydroxylase and vesicular acetylcholine transporter located in the pericellular nervous fibers and intracellular UCP1. The brown adipose cells of paBAT showed age-dependent decreases in UCP1 expression (P < 0.05), accompanied by a significant increase in vacuole formation, indicating fat accumulation (P < 0.05), from 10 to 37 years of age (P < 0.01). CONCLUSIONS: paBAT may be one of the essential sites for clinical application in BAT study because of its visible anatomy with feeding vessels and sympathetic/parasympathetic innervation functionally affected by outer condition and senescence.

Lymphatic pathway around the pancreatic head and extrahepatic bile duct: evaluation using MR imaging at 3.0-T.

PURPOSE: To evaluate the utility of spectral presaturation with inversion recovery (SPIR) T2-weighted images with 3-dimensional (3D) volume isotropic turbo spin echo acquisition (VISTA) at 3.0-T for the detection of the normal lymphatic systems located around the pancreatic head and extrahepatic bile duct. MATERIALS AND METHODS: Fifty-six patients with suspected hepatic or pancreaticobiliary diseases and diagnosed as normal or benign pathologies were evaluated as having normal lymphatic systems. The protocol consisted of SPIR T2-weighted sequences with 3D-VISTA. The lymphatic systems were defined as fluid signal intensity structures and divided into eight portions and interobserver agreement was evaluated using weighted kappa statistics. Three readers graded the visualization of each portion using a five-point scale. The detectability of each portion was calculated by defining grades 1-2 as detectable and grades 3-5 as undetectable. RESULTS: Interobserver agreement regarding the visualization grades was moderate to almost perfect. All readers rated the detectability of the lymphatic systems of the superior and posterior portions of the pancreatic head, pericholedochal, right abdominoaortic, and interaorticovenous portions as 100%, and that of the anterior portion of the pancreatic head as 98.2%. For the inferior portion of the pancreatic head, the detectability was 100% for reader 2 and 96.4% for readers 1 and 3. CONCLUSION: The lymphatic systems located around the pancreatic head and extrahepatic bile duct could be sufficiently visualized on SPIR T2-weighted images with 3D-VISTA at 3.0-T.

[Development of a computer-aided diagnosis system for the distinction between benign and malignant gastric lesions].

We proposed a method for a computer-aided diagnosis system that distinguishes between benign and malignant lesions in gastrointestinal digital radiography. To begin with, the level set method was applied in order to extract a tumor region from the image which was smoothed by the bilateral filter. Next, we selected four image features with the large SN ratio among various image features obtained from a tumor region using the Mahalanobis-Taguchi method, which has been employed mainly in quality engineering. The selected four image features-circularity, irregularity, size, and perimeter-were used as input data for the artificial neural network, which was employed for distinction between benign and malignant lesions. By using 43 regions of interest cropped from the 43 clinical cases, the area under the ROC curve (AUC) of diagnostic accuracy for the classification obtained with this proposed method was 0.970, whereas the average AUC obtained with 7 human observers (3 radiologists and 4 radiological technologist) was 0.941.

Impact of positron emission tomography/computed tomography in the management of patients with epithelial ovarian carcinoma after treatment.

PURPOSE: The aims of this study were to compare the usefulness and reliability of integrated whole-body positron emission tomography/computed tomography (PET/CT) using (18)F-fluorodeoxyglucose (FDG) with those of contrast-enhanced multidetector CT during regular follow-up in patients after initial treatment of ovarian cancer, to assess the impact of FDG-PET/CT on the confirmation of recurrence, restaging, and clinical management of patients, and to determine the incremental information provided by PET/CT. METHODS: A retrospective review was performed on 19 ovarian cancer patients who underwent a total of 30 FDG-PET/CT and contrast-enhanced multidetector CT scans. The following information was obtained: the clinical information of the patients; the results of FDG-PET/CT and contrast-enhanced multidetector CT, particularly with regard to the impact on the diagnosis of recurrence; information on the localization and number of diseases; and the impact on subsequent clinical management. RESULTS: Both FDG-PET/CT and contrast-enhanced multidetector CT had very high sensitivity and specificity for the detection of recurrent ovarian cancer. Contrast-enhanced multidetector CT was considered the more accurate imaging modality for detecting recurrence, whereas FDG-PET/CT was proven more effective for detecting large numbers of small lesions. When comparing the impact on the choice of a management plan, both FDG-PET/CT and contrast-enhanced multidetector CT were found to be significantly effective at predicting the locations of recurrence. CONCLUSIONS: Both integrated FDG-PET/CT and contrast-enhanced multidetector CT are sensitive surveillance modalities for the detection of recurrent ovarian cancer; the use of both modalities aids decisions on treatment plans and may ultimately have a favorable impact on prognosis. However, contrast-enhanced multidetector CT is recommended for the regular follow-up for ovarian cancer patients after initial treatment.

Radiotherapy combined with transarterial infusion chemotherapy and concurrent infusion of a vasoconstrictor agent for nonresectable advanced hepatic hilar duct carcinoma.

BACKGROUND: The treatment of patients with advanced hepatic hilar duct carcinoma is a challenging problem. The current study was performed to evaluate the outcome of patients with advanced hepatic hilar duct carcinoma who received external beam radiotherapy (EBRT) combined with transarterial chemotherapy and infusion of a vasoconstrictor. METHODS: Between April 1993 and December 2002, 23 patients with histopathologically confirmed hilar duct carcinoma entered the study. The median total dose of EBRT was 41.4 grays (Gy). Transarterial chemotherapy was performed twice during EBRT. It was comprised of an infusion of a cocktail of 20 mg of epirubicin, 10 mg of mitomycin C, and 500 mg of 5-fluorouracil and was administered 1 minute after injection of epinephrine via a catheter introduced in the hepatic arteries. After the combined treatment, the patients underwent biliary endoprosthesis after evaluation of the initial response to treatment by percutaneous transhepatic cholangiography (PTC). The initial responses based on PTC were classified into four categories: CR, no stenosis; PR, relief of stenosis/obstruction; NC, no change; and PD, progressive stenosis/obstruction. The outcome parameters were survival rates and time, as well as frequency and type of complications. RESULTS: Excluding 1 patient who discontinued the treatment, the initial responses of 22 patients were 1 CR (5%), 8 PR (36%), 11 NC (50%), and 2 PD (9%). The response rate was 41%. The overall survival rates at 1 year, 2 years, and 3 years after treatment were 59%, 36%, and 18%, respectively. CONCLUSIONS: The combination of radiotherapy, transarterial infusion chemotherapy, and concurrent infusion of a vasoconstrictor can be delivered safely with good efficacy for patients with advanced hilar duct carcinoma.

Ethanol injection therapy of an isolated bile duct associated with a biliary-cutaneous fistula.

Bile leakage after hepatic resection often results in the formation of a biliary-cutaneous fistula. Such a fistula, when caused by an isolated bile duct in the remnant liver, can be intractable. We report a successful case of ethanol injection therapy of an isolated bile duct. A 73-year-old man underwent right hepatic resection for hepatocellular carcinoma. Bile leakage occurred after surgery, and the patient developed a biliary-cutaneous fistula. Fistulography revealed an isolated bile duct in the remnant portion of the caudate lobe without communication to the main biliary system. As conservative management with simple drainage was ineffective, injection therapy with ethanol was performed with a balloon occlusion catheter. After 11 therapy sessions, the bile duct was eradicated, and the biliary- cutaneous fistula was completely healed. The post-treatment course was uneventful. Ethanol injection therapy can be a choice for management of patients with a biliary fistula caused by an isolated bile duct.