[Efficacy of multidirection MRCP]

Pancreatobiliary system has complex and thin structure except for gallbladder, thereby MRCP having lower spatial resolution gives sufficient information compared with the direct cholangiopancreatography. Multidirection MRCP using HASTE sequence obtains the data in plane to compensate the lower spatial resolution, thus high detectability of all over pancreatobiliary system is performed in a few minutes. This technique overcomes the demerits pointed by former investigators and gives sufficient information to diagnose the pancreatobiliary diseases.

High-resolution contrast-enhanced MRI of the uterus with a phased-array multicoil

High-resolution contrast-enhanced dynamic MRI of the uterus can be performed with the combination of a phased-array multicoil and fast GE techniques. This technique can improve the ability to visualize normal anatomy of the uterus and periuterine tissues, including vascular structures and pelvic ligaments, and to detect pathologic processes of the uterus and determine their extent.

Progressive viral-induced cirrhosis: serial MR imaging findings and clinical correlation

PURPOSE

To determine which magnetic resonance (MR) imaging findings of cirrhosis change as disease severity progresses.

MATERIALS AND METHODS

Seventy-six abdominal MR imaging studies in 38 patients (two per patient) with Child-Pugh grade A cirrhosis were retrospectively reviewed. All patients were followed up clinically and with MR imaging for 12 months or longer. MR images were used to determine volume indexes of the spleen and of each liver segment, as well as changes in hepatic contour, iron or fat deposition, and presence of varices and collateral vessels.

RESULTS

During follow-up in patients with progressive cirrhosis (n = 13), the volume indexes of the anterior, posterior, and medial segments of the liver decreased significantly (P = .011, .013, .002, respectively), and the number of varices and collateral vessels increased significantly (P = .018). In patients with stable cirrhosis (n = 25), the volume indexes of the spleen, caudate lobe, and lateral segment increased significantly (P = .032, .018, .003, respectively). The atrophic index was significantly greater in progressive cirrhosis than in stable cirrhosis (P = .009).

CONCLUSION

Progressive atrophy of the right hepatic lobe and the medial segment correlated with progression of clinical severity of cirrhosis, whereas increasing size of the caudate lobe and the lateral segment correlated with stability.

Splenic hamartoma presenting as a "hot spot" on Tc-99m phytate SPECT imaging

The cases of two patients with surgically proven splenic hamartomas with "hot spots" on Tc-99m phytate SPECT imaging are presented. There was intense radiocolloid accumulation in the peripheral portion of a large single tumor in one patient, and in each of three isolated tumors in the other patient. The intense uptake might be related to the function of proliferated reticuloendothelial cells in the tumors. These unique findings were not clearly identified on the planar images.

Differential diagnosis of hepatic tumors with delayed enhancement at gadolinium-enhanced MRI: a pictorial essay

Hepatic lesions with delayed enhancement are sometimes encountered on gadolinium-enhanced MRI of the liver. This study illustrates the varied appearances of several pathologic entities with delayed enhancement, including hepatic hemangioma, hepatic metastases, intrahepatic cholangiocarcinoma, focal nodular hyperplasia, hepatic abscess, hepatocellular carcinoma, and hepatocellular carcinoma after transcatheter arterial chemoembolization, and presents the utility of arterial-phase dynamic MRI in the differential diagnosis of these lesions. Possible causes of these delayed enhancements are also discussed.

Dynamic MR follow-up of small hepatocellular carcinoma after percutaneous ethanol injection therapy

For patients with small hepatocellular carcinomas (HCCs) treated by percutaneous ethanol injection (PEI) therapy, dynamic MRI has been performed to evaluate the therapeutic efficacy at our institute. In this pictorial essay, we illustrate the various dynamic MR findings of HCCs after PEI therapy, including complete necrosis, partial necrosis, local recurrence, and pathologic conditions such as arterioportal shunt and contractive changes of hepatic parenchyma. We also present the limitation of dynamic MRI in the evaluation of therapeutic effectiveness of PEI therapy.

Takayasu arteritis: MR manifestations and diagnosis of acute and chronic phase

Diagnosis of Takayasu arteritis is difficult because the clinical features are similar to those of other diseases. In the late occlusive or pulseless phase Takayasu arteritis, angiography usually demonstrates luminal changes such as such as stenosis, occlusion, or aneurysmal dilatation of the aorta and pulmonary artery and of their branches. However, absence of such luminal changes does not exclude the possibility of early or systemic phase Takayasu arteritis. Cross-sectional scanning such as CT scan and MRI plays an important role in demonstrating arterial wall changes in the early diagnosis of Takayasu arteritis. Improvement in the clinical findings and subsidence of the active inflammatory process can be expected with early steroid treatment. The common and uncommon MR appearances of the late occlusive phase and the recently described radiographic features of the early systemic phase are illustrated.

Homogeneous enhancement of hepatic parenchyma: MR imaging during arterial portography versus CT during arterial portography

BACKGROUND

The goal of this study was to investigate the frequency of inhomogeneous parenchymal enhancement of the liver in magnetic resonance imaging during arterial portography (MRAP) versus computed tomography during arterial portography (CTAP).

METHODS

CTAP and MRAP were performed in 29 and in 21 patients, respectively, who had suspected primary or secondary liver tumors on clinical or biological grounds. We evaluated the frequency of inhomogeneous hepatic parenchymal enhancement not related to a decrease of portal blood supply due to compression or obstruction by the tumor and physiologic variation in portal perfusion. Inhomogeneous parenchymal enhancement of the liver was classified as segmental or subsegmental and as nonsegmental.

RESULTS

Segmental or subsegmental inhomogeneous parenchymal enhancement was seen in six of 29 patients (20.1%) on CTAP and in one of 21 patients (4.8%) on MRAP. Nonsegmental inhomogeneous parenchymal enhancement was seen in five of 29 patients (17.2%) on CTAP images and in none of the patients (0%) on MRAP images. The incidence of nonsegmental inhomogeneous parenchymal enhancement was significantly lower on MRAP than on CTAP.

CONCLUSION

MRAP was superior to CTAP in achieving homogeneous parenchymal enhancement of the liver.

[Development of an instrument to measure self-care agency for the chronic ill in later adulthood--the first step of development]

The purpose of this study was to develop the instrument to measure self-care agency for the Japanese chronic ill in later adulthood and to test reliability and validity of that. First, the Self-Care Agency instrument draft which consists of 56 items rated along a 5-point Likert scale was developed. This draft was based upon the work of Orem (1991) and qualitative data of the Japanese chronic patients. Second, reliability and validity of this instrument was tested. The instrument was reviewed by 5 expert nurses and 16 nursing researchers for content validity. And this instrument was reviewed by 19 Japanese chronic patients for face validity. By result of content validity and face validity, this draft was refined. Next, the internal consistency, stability, and construct validity of this refined instrument was tested. The internal consistency of the instrument, as measured by the Cronbach's alpha, was 0.90 for a sample of 200 Japanese chronic patients. This instrument had a test-retest coefficient of r = 0.86 for a sample of 104 Japanese chronic patients. Using factor analytic techniques, five subscales emerged. These subscales gave some agreement with subscales that had been obtained before factor analysis. Therefore, construct validity of the instrument was established in some degree. And the subscale 'get a valid support' which emerged in this instrument was reflect Japanese cultural factor. Reliability and validity of this instrument were obtained in some degree. Further, it is necessary to refine this instrument, considering this research result.

Gallbladder disease: appearance of associated transient increased attenuation in the liver at biphasic, contrast-enhanced dynamic CT

PURPOSE

To evaluate the frequency, location, and appearance of transient increased attenuation in the liver during arterial-phase helical or incremental computed tomography (CT) in patients with gallbladder disease without hepatic extension.

MATERIALS AND METHODS

Findings in dynamic CT examinations in 31 patients with surgically proved gallbladder disease not extending into the liver and in 31 control patients without gallbladder disease were retrospectively reviewed and correlated with findings in other imaging examinations.

RESULTS

Areas of transient increased hepatic attenuation (n = 27) were identified in 22 of 31 patients with gallbladder disease and in only one of 31 control patients. The difference in these findings was statistically significant (P < .001). In the 27 areas of transient increased hepatic attenuation, these findings were categorized as curvilinear or nodular attenuation adjacent to the gallbladder fossa in 13 (48%), segmental or subsegmental attenuation in segment IV and/or V in seven (26%), lobar attenuation in the left lobe (segments II-IV) in four (15%), and nodular attenuation seen as an early enhancing "pseudolesion" in segment IV in three (11%). Hepatic angiography performed in 10 of the 22 patients showed early depiction of the dilated cystic vein (n = 8) and direct communication with the portal branches (n = 2).

CONCLUSION

Transient increased attenuation in the liver had a variable appearance at dynamic arterial-phase CT in most patients with gallbladder disease. This attenuation was most likely due to increased blood flow from the hepatobiliary system.

CT of acquired abnormalities of the portal venous system

Computed tomography (CT), including biphasic contrast material-enhanced helical dynamic scanning and three-dimensional CT angiography, is useful in evaluating acquired abnormalities of the portal venous system. At contrast-enhanced CT, portal venous thrombus usually manifests as low-attenuation intraluminal lesions combined with enlargement of the affected portal vein. Cavernous transformation, a masslike network of intertwined veins that provides an alternative pathway for a stenosed or occluded portal vein, is depicted as multiple, periportal vascular structures. At helical dynamic CT, arterioportal shunts manifest as early enhancement of the affected portal vein, transient hyperperfusion abnormalities with lobar or segmental distribution, or transient wedge-shaped enhancement peripheral to the tumor. In patients with portosplenic venous invasion by malignant neoplasms, peripancreatic or perigastric veins may dilate if they function as hepatopetal collateral veins. In patients with portal hypertension, a variety of hepatofugal collateral pathways can develop, including esophageal, paraesophageal, coronary gastric, inferior phrenic, paraumbilical, abdominal wall, splenorenal, gastrorenal, retrocaval, and mesocaval collateral pathways. An understanding of the varied CT appearances of acquired abnormalities of the portal venous system will allow more definitive diagnosis and help avoid false diagnosis of disease.

Biphasic contrast-enhanced multisection dynamic MR imaging of the liver: potential pitfalls

Biphasic contrast material-enhanced dynamic magnetic resonance (MR) imaging is an important technique for evaluating liver disease. However, several potential diagnostic pitfalls may be encountered, including lobar, segmental, subsegmental, and subcapsular hyperperfusion abnormalities; early-enhancing pseudolesions, particularly in the medial segment of the left hepatic lobe; heterogeneous hyperperfusion abnormalities throughout the liver; and hypointense pseudolesions due to vascular artifacts, unenhanced hepatic vessels, partial volume artifacts, magnetic susceptibility artifacts, and regenerative nodules in cirrhosis. These abnormalities sometimes have appearances similar to those of true lesions or tumor spread to the surrounding liver parenchyma on arterial-dominant phase dynamic MR images. In most cases, however, no corresponding abnormalities are seen with other pulse sequences or on delayed-phase MR images. In addition, hyperperfusion abnormalities due to readily recognizable causes are often found in characteristic locations and thus can be differentiated from true tumors. An understanding of the causes of these potential pitfalls and how to avoid them will help radiologists understand and correctly interpret images.

Renal parenchymal malakoplakia in a four-week-old infant

We describe a four-week-old male infant with bilateral renal parenchymal malakoplakia who presented with low grade fever, convulsions and lethargy. The patient had profound anemia, hepatosplenomegaly and bilateral nephromegaly with reduced renal function. Both blood and urine cultures grew Escherichia coli, and antibiotic therapy was started. A kidney biopsy obtained on the 20th hospital day confirmed the diagnosis of renal parenchymal malakoplakia. Following treatment with an intravenous methylprednisolone pulse therapy, the infant made significant clinical improvement. He has grown and developed normally in the three years following this episode. We suggest that the steroid therapy was useful in ameliorating renal parenchymal malakoplakia in a patient without an underlying systemic disease. This report describes the youngest patient to have malakoplakia.

Immunosuppression by inhibition of cellular adhesion mediated by leukocyte function-associated antigen-1/intercellular adhesion molecule-1 in murine cardiac transplantation

BACKGROUND

Donor alloantigen-specific tolerance to vascularized allografts can be induced by several treatments, but the immunological mechanism(s) of these effects remain unclear. One hypothesis is that allograft unresponsiveness is correlated with a shift in the pattern of expression of the T helper 1 versus T helper 2 T-cell cytokines. We report here an extensive analysis of murine cardiac allografts, during normal first set rejection and in mice treated with anti-adhesion molecule monoclonal antibodies (mAbs), a regimen that results in prolonged unresponsiveness.

METHODS

A combination of immunohistochemical staining with a panel of mAbs, and in situ hybridization with a panel of digoxigenin-labeled riboprobes, was performed on frozen-tissue sections of cardiac allografts.

RESULTS

In several strain combinations, injection of anti-leukocyte function-associated antigen-1 and anti-intercellular adhesion molecule-1, from day 0 to day 6 after transplantation, results in significant long-term survival. Examination of tolerated cardiac allografts by in situ hybridization and immunohistochemical staining shows an altered cytokine expression pattern, although the frequency of CD3 and CD4 cells is not dramatically reduced. These allografts show a decreased frequency of interferon-gamma and interleukin (IL)-2-expressing cells and a slightly increased frequency of cells expressing IL-4 and IL-10, compared with unmodified acute rejection. A direct role of these changes in T-cell cytokine expression is demonstrated by reversal of tolerance induction and rejection of the allograft by in vivo injection of either anti-IL-10 or anti-IL-4 mAb.

CONCLUSIONS

Although there are significant differences in the frequency of different cellular subsets and patterns of cytokine gene expression, these differences are quantitatively subtle, suggesting a delicately balanced immune response that can develop a pattern of specific unresponsiveness, with relatively minor alterations in the specific T-cell response.

High-resolution dynamic MR imaging of hepatocellular carcinoma with a phased-array body coil

High spatial resolution dynamic magnetic resonance (MR) imaging performed with a phased-array body coil is a useful tool for evaluating hepatocellular carcinoma. The examination consists of fast spin-echo T1- and T2-weighted images obtained in a single breath hold; multisection, dynamic, fast gradient-echo images obtained in a single breath hold; and contrast material-enhanced images obtained in the arterial-dominant and delayed phases. Hepatocellular carcinoma, with its predominantly arterial blood supply, usually appears hyperintense on arterial-dominant phase images and isointense or hypointense relative to liver parenchyma on delayed-phase images. Hepatocellular carcinomas, especially those larger than 1.5 cm, contain a fibrous capsule or an inner septum, which allows them to be differentiated from other tumors. These characteristics are particularly important in the diagnosis of hypovascular hepatocellular carcinomas, which do not have an arterial blood supply and thus do not enhance. Extracapsular invasion, a relatively common finding in advanced cases, is seen as a nodular enhancing area that projects into the surrounding liver parenchyma adjacent to the main tumor on arterial-dominant phase images and as an iso- or hypointense area on delayed-phase images. Portal vein invasion appears as an obstruction of the vein, and portal vein tumor thrombi appear as intermediate-signal-intensity masses. The technique can also be helpful in the follow-up of treatment.

Hepatic parenchymal hyperperfusion abnormalities detected with multisection dynamic MR imaging: appearance and interpretation

On arterial-dominant-phase images in multisection dynamic MR imaging, early-enhancing areas that are perfusion abnormalities rather than tumor deposit are sometimes encountered. The purpose of this article was to determine the frequency, location, and appearance of these hepatic parenchymal hyperperfusion abnormalities and to discuss possible causes of these abnormalities. Multisection dynamic MR images obtained in 415 patients with suspected hepatobiliary diseases were reviewed for the presence of hyperperfusion abnormalities. A total of 96 hyperperfusion abnormalities were identified in 88 (21%) of 415 patients. They were characterised from their shape, distribution, or location as lobar or segmental (n = 36 [38%]), subsegmental (n = 32 [33%]), or subcapsular (n = 28 [29%]) hyperperfusion abnormalities. Presumable etiologies were considered as follows: (a) compression, obstruction, or ligation of the portal vein; (b) siphoning effect by tumor; (c) aberrant cystic venous drainage; (d) percutaneous ethanol injection; (e) percutaneous needle biopsy; (f) rapid drainage by the subcapsular vein; or (g) cirrhosis or unknown. A significant percentage of patients had hepatic hyperperfusion abnormalities. Familiarity with these hyperperfusion abnormalities on multisection dynamic MR images is important to prevent false-positive diagnoses.

Chromosome spreading techniques for primary gastrointestinal tumors

The requirement for well spread out chromosomes for the cytogenetic analysis of primary gastrointestinal tumors led us to develop new techniques. These techniques involved two main procedures: (1) preliminary incubation with culture medium in the presence of collagenase, Dispase, and colcemid, for 3 h, and (2) treatment with an extremely hypotonic solution (0.044M KCl) for 30 min. The techniques were applied to 11 gastrointestinal malignancies (including 1 early gastric cancer and 1 metastatic liver lesion of colon cancer) and significant increases (P < 0.01) in the number of metaphases of analyzable karyotypes were obtained, compared with a previous method in which the standard hypotonic molarity of KCL (0.075 M) was employed. The mean value for metaphase numbers of the analyzable karyotypes was 37.0 +/- 3.7% in the 5 gastric cancers and 44.7 +/- 4.8% in the 5 colon cancers and 1 metastatic lesion. These values were three times and more than twice, respectively, the values obtained by the previous method. A fluorescence in situ hybridization (FISH) study was carried out on one cologenic tumor, the alpha-satellite centromere-specific probe 17 being used. Deletion of the long arm of chromosome 17 was demonstrated. The method proposed here could yield a sufficient number of metaphases without the use of tissue culture that might cause alteration of karyotype. It can be employed with small biopsy specimens and in studies utilizing the FISH technique.

Liver neoplasms: diagnostic pitfalls in cross-sectional imaging

The appearances of most common liver neoplasms at computed tomography (CT) and magnetic resonance (MR) imaging have been established. However, there are considerable overlaps in the appearances of various pathologic entities. Certain hepatic lesions, such as hepatic hemangioma, adenoma, focal nodular hyperplasia, intrahepatic cholangiocarcinoma, metastases, hepatocellular carcinoma, regenerative nodules, adenomatous hyperplastic nodules, abscess, and hepatocellular carcinoma treated with transcatheter arterial chemoembolization, can have unusual characteristics at CT and MR imaging that may lead to misinterpretation. Dynamic helical CT and double-phase multisection dynamic MR imaging techniques may be helpful in differentiating between these entities because hemodynamics of the lesion can be evaluated by obtaining both arterial-phase and delayed-phase images. It is important for radiologists to be aware of these uncommon appearances of liver neoplasms. Familiarity with these varied CT and MR imaging features will permit a more accurate diagnosis and aid in avoidance of a false diagnosis.

Hepatic parenchymal changes after ethanol injection in rabbits: correlation of conventional and dynamic MR imaging with pathologic findings

The purpose of this study is to clarify the changes of peripheral normal liver parenchyma before and after ethanol injection, with respect to MR appearances and pathologic findings and, in so doing, to clinically evaluate the therapeutic effectiveness of percutaneous ethanol injection (PEI) therapy. The normal liver in 12 rabbits was injected with ethanol. We performed conventional and dynamic MR imaging and prepared the histopathologic specimens 1 week (group 1), 2 weeks (group 2), and 1 month (group 3) after ethanol injection. On conventional MR images, coagulative necrosis in the normal liver was demonstrated as an area of low signal intensity on T1-weighted images and high signal intensity on T2-weighted images in all groups. On dynamic MR images, contrast enhancement in the coagulative necrosis was not seen in groups 1 and 2; however, gradual and concentric enhancement was seen in the direction of the central necrotic portion from early-to-delayed phase image in group 3. Although signal intensity of the coagulative necrotic area in the normal liver after ethanol injection may mimic that of untreated or viable hepatocellular carcinoma (HCC) when clinically encountered on conventional MR images, coagulative necrosis of the normal liver parenchyma will be discriminated from viable HCC by using dynamic MR imaging.

[Outpatient chemotherapy with continuous infusion of 5-fluorouracil (CI 5-FU) and intravenous bolus leucovorin (IVB LV) in advanced gastrointestinal cancer: the second report]

This study was designed to evaluate the efficacy, toxicity, and quality of life (QOL) of outpatient chemotherapy with 5-FU and LV in advanced gastrointestinal cancer. Treatment consisted of CI 5-FU 450 mg/body/day, days 1-28, IVB LV 30 mg/body q wk (schedule, sch. A) and CI 5-FU 200 mg/m2/day, days 1-28, IVB LV 20 mg/m2 q wk (sch. B). 5-FU was administered with the Baxter infusor (0.5 ml/hr). Oral UFT (400-600 mg/day) was administered after these chemotherapy. Sixteen patients (pts) (sch. A 9 pts, sch. B 7 pts) with advanced gastrointestinal cancer have been treated to maintain the efficacy of prior inpatient chemotherapy. Twenty pts treated as adjuvant chemotherapy were added to evaluate toxicity and QOL. The median time to progression in sch. A was 3.0 months and sch. B was 2.4 months. Grade 3 or 4 toxicities of mucositis were seen 40% in sch. A and 0% in sch. B. Grade 1 or 2 skin toxicities were seen 100% in sch. A and 52% in sch. B. Mean score of QOL in sch. A was 78.0 +/- 11.5, sch. B was 89.5 +/- 7.8 ranked between inpatient chemotherapy (5-FU + CDDP 59.0 +/- 13.8) and UFT (91.8 +/- 6.1). In conclusion, these schedule of 5-FU and LV combination offers a high patient QOL and is suitable for advanced gastrointestinal cancer treatment.

Single cell analysis of cytokine gene coexpression during CD4+ T-cell phenotype development

CD4+ T cells from alpha beta-T-cell receptor transgenic mice were analyzed for coexpression of cytokine mRNAs during phenotype development using a double-label in situ hybridization technique. T cells that produced cytokines in the primary response were a fraction of the activated population, and only a minority of the cytokine-positive cells coexpressed two cytokines. In secondary responses, frequencies of double-positive cells increased, although they remained a minority of the total. Of the cytokine pairs examined, interleukin (IL)-4 and IL-5 were the most frequently coexpressed. IL-4 and interferon gamma showed the greatest tendency toward segregation of expression, being rarely coexpressed after the primary stimulation. These data indicate that there is significant heterogeneity of cytokine gene expression by individual CD4+ T cells during early antigenic responses. Coexpression of any pairs of cytokines, much less Th1 and Th2 cytokines, is generally the exception. The Th0 phenotype is a population phenotype rather than an individual cell phenotype.