CT-quantified muscle and fat change in patients after surgery or endoscopic resection for early gastric cancer and its impact on long-term outcomes

The purpose of this study was to evaluate the impact of the body composition changes on patients' long-term outcomes after endoscopic resection or surgery for mucosal gastric cancer.This case-control study included 96 patients who underwent endoscopic resection or surgery after propensity score matching. Areas of fat and muscle measured on CT were compared between the 2 groups. The effects of the variables on disease-free and overall survival were assessed using Cox-regression analysis and Kaplan-Meier survival analysis.The median overall survival of the surgical and endoscopic resection groups was 91.1 and 93.9 months (P = .080). Fat area was decreased significantly more after surgery (P < .001). The number of patients with sarcopenia was increased in the surgery group. Kaplan-Meier plot showed that overall survival was significantly correlated with post-treatment sarcopenia (P = .049).CT-based body composition analysis was helpful to evaluate the change in fat and muscle areas after treatment of early gastric cancer. The losses of fat and muscle after treatment were negatively associated with the patient overall survival.

Reproducibility of mRECIST in Measurement and Response Assessment for Hepatocellular Carcinoma Treated by Transarterial Chemoembolization

RATIONALE AND OBJECTIVES

To evaluate the reproducibility of Modified Response Evaluation Criteria in Solid Tumors (mRECIST) for hepatocellular carcinoma (HCC) after transarterial chemoembolization (TACE) using multiphasic computed tomography.

MATERIALS AND METHODS

The institutional review board approved this retrospective study. We evaluated 97 patients who underwent TACE (60 conventional TACE [cTACE] and 37 drug-eluting bead TACE [DEB-TACE]) for HCC from 2010 to 2014. Four radiologists evaluated pairs of dynamic liver CTs scanned within 2 months before and after TACE based on mRECIST. Assessment of intra- or interobserver reproducibility for response categorization and sum of long diameter were evaluated using weighted kappa statistics (κ) and intraclass correlation coefficients, respectively. The relationship between concordance of target lesion selection and agreement of target lesion response was evaluated using Fisher exact test.

RESULTS

Intraobserver reproducibility for overall response was moderate to excellent (κ = 0.525-0.865). Interobserver reproducibility was improved on the second review compared to the first review and it was good in both treatment groups (κ = 0.627 for cTACE and 0.602 for DEB-TACE). Between the two treatment methods, intra- or interobserver reproducibility was better after cTACE than DEB-TACE. Intraclass correlation coefficients for sum of long diameter measurement showed excellent intra- or interobserver reproducibility. The concordance rate of target lesion selection was significantly higher for patients with radiologists' agreement for target lesion response than patients with disagreed response (P = .003).

CONCLUSIONS

The intra- and interobserver reproducibility of mRECIST in patients with HCC after TACE was moderate to excellent, and the reproducibility was slightly better after cTACE than DEB-TACE.

Evaluation of the prognostic value of the new AJCC 8th edition staging system for patients with pancreatic adenocarcinoma; a need to subclassify stage III?

BACKGROUND

There have been several proposed changes for the 8th edition of the American Joint Commission on Cancer (AJCC) for pancreatic adenocarcinoma. The aim of this study was to evaluate the prognostic value of the new staging system for patients with pancreatic adenocarcinoma, especially in stage III patients.

METHODS

We analysed the data of patients newly diagnosed with pancreatic adenocarcinoma between 2008 and 2016 at our hospital. Patients were staged according to 7th edition AJCC criteria, as well as the new 8th edition staging system. The pathologic stage was used in the surgical cases, and the clinical stage, determined by radiographic findings, was used in the unresectable cases.

RESULTS

Five hundred two patients were identified who met the inclusion criteria. In node-negative patients, there were no significant differences in survival among T 1, 2 and 3 groups according to the 8th edition. The survival rates of patients with N1 (1-3 positive nodes) and N2 (≥4 positive nodes) disease, according to 8th edition, were significantly different (p < 0.001). Although N2 and T4 patients are both stage III according to the new staging system, N2 patients had a better survival rate than T4 patients (p = 0.038). The new staging system stratifies patients more evenly across stages without sacrificing the prognostic accuracy.

CONCLUSIONS

The AJCC 8th edition has some advantages over the previous version. However, patients with N2 and T4, who have been integrated into stage III, showed different treatment modalities and prognoses, and we proposed dividing stage III into IIIA (T1-3N2M0) and IIIB (T4N_anyM0).

Splenic Infarction as a Delayed Febrile Complication Following Radical Gastrectomy for Gastric Cancer Patients: Computed Tomography-Based Analysis

BACKGROUND

The aim of this study was to evaluate the incidence and clinical characteristics of splenic infarction (SI) in gastric cancer patients who have undergone gastrectomy.

METHODS

For this study, the medical records of 1084 patients were reviewed and 877 patients were ultimately enrolled. The times of symptom onset, diagnosis of SI, and complete resolution on CT were calculated from the day of the operation. Based on the wedge shape of the SI in all cases, the total volume of the SI was measured based on that of a corn kernel.

RESULTS

Thirty-six patients (4.10%) were diagnosed with SI after gastrectomy; four of these patients (0.45%) developed complications associated with the SI. Total gastrectomy and extended lymph node dissection were risk factors for development of SI. Patients with complications exhibited inflammatory signs between 7 and 10 days after surgery. The mean volume of the SI was 4025.69 mm³. The mean time to complete resolution on the CT scan was 327 days postoperatively. In 30 cases, small branched arteries from the splenic artery that could have caused the SI were retrospectively detected on the preoperative CT scans.

CONCLUSION

Although the incidence of the SI was low, large volume of the SI is associated with complication development. Measuring the infarction volume via a CT scan may be useful to decide on the treatment strategy. Preoperative 3-D reconstruction of the splenic artery tributaries may help reduce the risk of inadvertent SI.

Location of Disease on Imaging may Predict Radiation Exposure During Endoscopic Retrograde Cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is performed for various diseases. The aim of this study is to evaluate the difference of dose-area product (DAP) during the ERCP procedures according to location of the lesion. We performed a retrospective study of consecutive 217 therapeutic ERCP examinations performed between November 2014 and April 2015 at a tertiary care center. ERCP procedures divided into two groups according to location of the lesion identified on imaging: lesions in the common hepatic duct (CHD) or the common bile duct (CBD) and lesions in the hepatic hilum or the intrahepatic duct (IHD). The mean DAP of the hilum-IHD group (48.7 Gy cm2) was significantly higher than that of the CBD-CHD group (34.9 Gy cm2) (P = 0.003). Radiation exposure during ERCP was significantly different according to location of bile duct lesion.

The Diagnostic Performance of Liver MRI without Intravenous Contrast for Detecting Hepatocellular Carcinoma: A Case-Controlled Feasibility Study

Objective

To preliminarily evaluate the diagnostic performance of an unenhanced MRI for detecting hepatocellular carcinoma (HCC) with a case-control study design.

Materials and Methods

The case group consisted of 175 patients with initially-diagnosed HCC, who underwent a 3T liver MRI. A total of 237 HCCs were identified. The number of HCCs that were smaller than 1 cm, 1 cm ≤ and < 2 cm, and ≥ 2 cm were 19, 105, and 113, respectively. For the control group, 72 patients with chronic liver disease, who did not have HCC, were enrolled. Two radiologists independently reviewed the T2 half-Fourier acquisition single-shot turbo spin echo, T2 fast spin echos with fat saturation, T1 gradient in- and out-of-phase images, and diffusion-weighted images/apparent diffusion coefficient maps to detect HCC. Per-patient analyses were performed to evaluate the sensitivity and specificity of the non-contrast MRI for diagnosing HCC. Furthermore, the per-lesion sensitivity was also calculated according to tumor size.

Results

In the per-patient analyses, the sensitivity and specificity of reader 1 were 86.3% (151/175) and 87.5% (63/72), respectively; while those of reader 2 were 82.9% (145/175) and 76.4% (55/72), respectively. When excluding HCCs smaller than 1 cm, the sensitivity of reader 1 and 2 were 88.0% (147/167) and 86.2% (144/167), respectively. In the per-lesion analyses, the sensitivities of reader 1 and reader 2 were 75.9% (180/237) and 70.5% (167/237), respectively.

Conclusion

The per-patient sensitivity and specificity of non-contrast MRIs were within a reasonable range for the initial diagnosis of HCC. Non-contrast MRIs may have a potential for surveillance of HCC. Further confirmatory diagnostic test accuracy studies are needed.

Preoperative sarcopenia and post-operative accelerated muscle loss negatively impact survival after resection of pancreatic cancer

BACKGROUND

Sarcopenia and post-operative accelerated muscle loss leading to cachexia are commonly observed in patients with pancreatic cancer. This study aimed to assess the influence of body compositions and post-operative muscle change on survival of patients with surgically treated pancreatic cancer.

METHODS

We analysed data of patients diagnosed with pancreatic adenocarcinoma who underwent surgery from 2008 to 2015. Skeletal muscle areas, muscle attenuation, and visceral and subcutaneous adipose tissue areas were measured from two sets of computed tomography images at L3 vertebral levels. In addition, muscle change was calculated from images obtained before and after cancer resection. We set our own cut-off values of various body compositions based on sex-specific tertiles.

RESULTS

A total of 180 patients were analysed. Patients with perioperative sarcopenia (n = 60) showed poorer overall survival than those without perioperative sarcopenia (P = 0.031). Fifty (28.6%) patients with accelerated muscle loss after surgery (>10%/60 days) had poorer survival compared with the others (P = 0.029). Sarcopenia (hazard ratio, 1.79: 95% confidence interval, 1.20-2.65] and post-operative muscle change (%/60 days) (hazard ratio, 0.94: 95% confidence interval, 0.92-0.96) were identified as significant predictors of survival on multivariable analyses.

CONCLUSIONS

Preoperative sarcopenia identified on CT scan was associated with poor overall survival in patients with pancreatic cancer following surgery. Accelerated muscle loss after surgery also negatively impacted survival in pancreatic cancer patients.

Sarcopenia is negatively associated with long-term outcomes in locally advanced rectal cancer

BACKGROUND

The association of sarcopenia and visceral obesity to treatment outcome is not clear for locally advanced rectal cancer. This study evaluates the influence of skeletal muscle and visceral fat on short-term and long-term outcomes in locally advanced rectal cancer patients treated with neoadjuvant chemoradiation therapy followed by curative resection.

METHODS

A total of 188 patients with locally advanced cancer were included between January 2009 and December 2013. Neoadjuvant chemoradiotherapy was followed by curative resection. Sarcopenia and visceral obesity were identified in initial staging CT by measuring the muscle and visceral fat area at the third lumbar vertebra level.

RESULTS

Among the 188 included patients, 74 (39.4%) patients were sarcopenic and 97 (51.6%) patients were viscerally obese. Sarcopenia and high levels of preoperative carcinoembryonic antigen were significant prognostic factors for overall survival (P = 0.013, 0.014, respectively) in the Cox regression multivariate analysis. Visceral obesity was not associated with overall survival; however, it did tend to shorten disease-free survival (P = 0.079).

CONCLUSIONS

Sarcopenia is negatively associated with overall survival in locally advanced rectal cancer patients who underwent neoadjuvant chemoradiation therapy and curative resection. Visceral obesity tended to shorten disease-free survival. Future studies should be directed to optimize patient conditions according to body composition status.

Educational Effects of Radiation Reduction During Fluoroscopic Examination of the Adult Gastrointestinal Tract

RATIONALE AND OBJECTIVES

This study aimed to evaluate the effects of educating radiology residents and radiographers about radiation exposure on reduction of dose area product (DAP) and fluoroscopy time in diagnostic fluoroscopy of the gastrointestinal (GI) tract in adult patients.

MATERIALS AND METHODS

In April 2015, we offered 1 hour of education to radiology residents and radiographers on how to reduce radiation doses during fluoroscopic examinations. Fluoroscopic examinations of the GI tracts of adult patients performed from June 2014 to February 2016 were evaluated. A total of 2326 fluoroscopic examinations (779 and 1547 examinations before and after education, respectively) were performed, including 10 kinds of examinations. Fluoroscopy time and DAP were collected. A radiologist evaluated the number of spot images, captured images, cine video, captured video, and the use of collimation or magnification. We used the Mann-Whitney U test to assess the difference in fluoroscopy-related factors before and after education.

RESULTS

Median DAP decreased significantly after education, from 21.1 to 18.2 Gy∙cm² (P < .001) in all examinations. After education DAP decreased significantly in defecography (P < .001) and fluoroscopy time decreased significantly in upper gastrointestinal series with water-soluble contrast (P < .001). Spot and cine images that increased the radiation dose were used less frequently after education than before in some kinds of examinations, especially in defecography (P < .001). More images were collimated after education in barium swallow than before (P < .001).

CONCLUSIONS

Educating radiologist residents and radiographers could reduce DAP in fluoroscopy examinations of the GI tract in adult patients.

Quality Management of Ultrasound Surveillance for Hepatocellular Carcinoma Under the Korean National Cancer Screening Program

OBJECTIVES

The aim of this study was to investigate the quality of ultrasound (US) examinations for hepatocellular carcinoma surveillance under the Korean National Cancer Screening Program and to assess knowledge and experience about liver US of physicians who perform US examinations.

METHODS

The investigation about the quality of liver US for hepatocellular carcinoma screening was based on the results of a nationwide quality assurance (QA) evaluation between 2012 and 2014 at all medical institutions participating in the National Cancer Screening Program. The QA evaluation was for personnel, equipment, education, and clinical images. Medical institutions with fewer than 60 of 100 points were considered to have failed the evaluation. Follow-up education in the form of a hands-on workshop was provided for physicians who worked in medical institutions that failed the QA evaluation. A questionnaire about basic knowledge and experience with US was administered during follow-up education.

RESULTS

After the QA evaluation, 542 of 685 hospitals and 1340 of 1985 private clinics passed the test. The evaluation of private clinics and hospitals showed substantial differences in the frequency of adequacy or mean scores between the pass and fail groups for all QA items, even requirements. Among 233 participants in the hands-on workshops, 187 physicians (80.2%) responded to the questionnaire. Results revealed that physicians had deficient knowledge and experience about liver US.

CONCLUSIONS

The quality of liver US for hepatocellular carcinoma screening remains suboptimal. Education for physicians who perform liver US examinations is unsatisfactory in Korea. We should make an effort to improve the quality of liver US and teach basic US techniques to physicians.

Comparison of biannual ultrasonography and annual non-contrast liver magnetic resonance imaging as surveillance tools for hepatocellular carcinoma in patients with liver cirrhosis (MAGNUS-HCC): a study protocol

Background

Ultrasonography (US) is recommended as a standard surveillance tool for patients with a high risk of developing hepatocellular carcinoma (HCC). However, the low sensitivity of US for small HCC can lead to surveillance failure, resulting in advanced stage tumor presentations. For the early detection of HCC in high-risk patients and to improve survival and prognosis, a new efficient imaging tool with a high sensitivity for HCC detection is needed. The purpose of this study is to evaluate and compare the feasibility and efficacy of non-contrast magnetic resonance imaging (MRI) with US as a surveillance tool for HCC in patients with liver cirrhosis.

Methods

MAGNUS-HCC is a prospective, multicenter clinical trial with a crossover design for a single arm of patients. This study was approved by six Institutional Review Boards, and informed consent was obtained from all participants. All patients will undergo liver US every 6 months and non-contrast liver MRI every 12 months during a follow-up period of 3 years. If a focal liver lesion suspected of harboring HCC is detected, dynamic liver computed tomography (CT) will be performed to confirm the diagnosis. After the last surveillance round, patients without suspicion of HCC or who are not diagnosed with HCC will be evaluated with a dynamic liver CT to exclude false-negative findings. The primary endpoint is to compare the rate of detection of HCC by US examinations performed at 6-month intervals with that of yearly non-contrast liver MRI studies during a 3-year follow-up. The secondary endpoint is the survival of the patients who developed HCC within the 3-year follow-up period.

Discussion

MAGNUS-HCC is the first study to compare the feasibility of non-contrast MRI with US as a surveillance tool for the detection of HCC in high-risk patients. We anticipate that the evidence presented in this study will establish the efficacy of non-contrast MRI as a surveillance tool for HCC in high-risk patients.

Trial registration

The date of trial registration (NCT02551250) in this study was September 15, 2015, and follow-up is still ongoing.

Evaluation of treatment pattern and symptom control in patients with gastroesophageal reflux disease: multihospital questionnaire survey on the current situation in Korea

Proton pump inhibitors (PPIs) are the most effective treatment for gastroesophageal reflux disease (GERD); however, a considerable number of patients fail to respond to PPI therapy and complain of nocturnal heartburn and sleep disturbance. The aims of this study are to evaluate the treatment pattern of GERD-related medications and their efficacy in relieving nocturnal heartburn. A total of 334 patients with GERD receiving PPI therapy within 6 months were enrolled in a multihospital questionnaire survey from January, 2014 to March, 2015. GERD symptoms and patients' satisfaction were assessed by patient questionnaires, and treatment patterns of GERD-related medications were assessed by investigators. Among the 334 patients, 95.8% used PPI once daily and 58.6% used a half-dose of PPI. The PPI treatment pattern was changed in 26.6% of all patients, of those, 54% of the patients doubled the PPI dose, and 29.2% of the patients switched to another PPI. Approximately 60.3% of all patients were prescribed more than three GERD-related medications. The overall satisfaction rate was 61.8%, and 32.2% of patients experienced nocturnal heartburn and sleep disturbance. In the extended-release PPI group, there were fewer nocturnal symptoms compared with the conventional PPI group (10% vs. 33.7%, respectively, P = 0.027). The use of more than three medications was inversely associated with patients' satisfaction (OR = 0.355, 95% CI; 0.197-0.642, P = 0.001). Most patients were prescribed adjunctive medications other than PPIs; however, patients' satisfaction was inversely associated with multiple drugs. Patients' satisfaction was superior in extended-release PPIs than conventional PPIs for the relief of nocturnal heartburn in Korean patients.

Clinical Significance of Discordance between Carcinoembryonic Antigen Levels and RECIST in Metastatic Colorectal Cancer

Purpose

The purpose of this study was to investigate the prognostic implications of carcinoembryonic antigen (CEA) levels that are inconsistent with Response Evaluation Criteria in Solid Tumor (RECIST) responses in metastatic colorectal cancer patients.

Materials and Methods

We retrospectively evaluated 360 patients with at least one measurable lesion who received first-line palliative chemotherapy. CEA-response was defined as CEA-complete response (CR; CEA normalization), CEA-partial response (PR; ≥ 50% decrease in CEA levels), CEA-progressive disease (PD; ≥ 50% increase in CEA levels), and CEA-stable disease (SD; non-CR/PR/PD). Overall survival (OS) and progression-free survival (PFS) were evaluated according to CEA-response.

Results

In RECIST-PR patients, poorer CEA-response was associated with disease progression at the subsequent evaluation. In RECIST-SD patients, CEA-CR and -PR were associated with lower disease progression rates than CEA-PD at the subsequent evaluation. Correlations between survival outcome and CEA-response in same-category RECIST patients were assessed. In RECIST-PR patients, discordant CEA-response (CEA-PD/SD) was associated with poorer survival than CEA-CR/PR (median OS and PFS, 44.0 and 15.4 [CEA-CR], 28.9 and 12.5 [CEA-PR], 21.0 and 9.8 [CEA-SD], and 13.0 and 7.0 [CEA-PD] months, respectively; all p < 0.001). In RECIST-SD patients, favorable CEA-response produced better survival (median OS and PFS, 26.8 and 21.0 [CEA-CR], 21.0 and 11.0 [CEA-PR], 16.1 and 8.2 [CEA-SD], and 12.2 and 6.0 [CEA-PD] months, respectively; all p < 0.001). RECIST-PD patients with CEA-CR showed longer OS than those with CEA-PD. Multivariate analysis demonstrated that discordant CEA-response is a powerful prognostic factor for RECIST-PR and RECIST-SD patients.

Conclusion

Among patients of the same RECIST-response categories, CEA-response patterns are significantly prognostic and strongly predictive of subsequent evaluation outcomes.

Impact of Fatty Liver on Acute Pancreatitis Severity

Aim. Acute pancreatitis is typically a mild disease, but some patients develop severe courses. Fatty liver changes are seen in patients with acute pancreatitis, but its clinical significance has not been well-studied. We aimed to investigate the relationship between fatty liver and the severity of acute pancreatitis. Methods. Unenhanced CT images of patients with acute pancreatitis were retrospectively reviewed by a radiologist, and mean hepatic and splenic attenuation was measured in Hounsfield units (HU). Fatty liver was defined as mean hepatic/splenic HU < 1. Results. Among 200 patients, fatty liver was found in 67 (33.5%) and nonfatty liver in 133 (66.5%). Compared with patients without fatty liver, the severity of pancreatitis and levels of serum C-reactive protein were higher in fatty liver patients. The prevalence of local complications, persistent organ failure, and mortality were also higher in patients with fatty liver. Even after adjusting for age, sex, body mass index, and cause of pancreatitis, fatty liver was significantly associated with moderately severe or severe acute pancreatitis. Conclusions. Fatty liver may play a prognostic role in acute pancreatitis. Fatty liver could be incorporated into future predictive scoring models.

Pancreatic hardness: Correlation of surgeon’s palpation, durometer measurement and preoperative magnetic resonance imaging features

AIM

To evaluate the correlation between subjective assessments of pancreatic hardness based on the palpation, objective measurements using a durometer, and magnetic resonance imaging (MRI) findings for assessing pancreatic hardness.

METHODS

Eighty-three patients undergoing pancreatectomies were enrolled. An experienced surgeon subjectively evaluated the pancreatic hardness in the surgical field by palpation. The pancreatic hardness was also objectively evaluated using a durometer. Preoperative MRI findings were evaluated by a radiologist in terms of the apparent diffusion coefficient (ADC) values, the relative signal intensity decrease (RSID) of the pancreatic parenchyma, and the diameter of the pancreatic parenchyma and duct. Durometer measurement results, ADC values, RSID, pancreatic duct and parenchyma diameters, and the ratio of the diameters of the duct and parenchyma were compared between pancreases judged to be soft or hard pancreas on the palpation. A correlation analysis was also performed between the durometer and MRI measurements.

RESULTS

The palpation assessment classified 44 patients as having a soft pancreas and 39 patients as having a hard pancreas. ADC values were significantly lower in the hard pancreas group. The ductal diameter and duct-to-pancreas ratio were significantly higher in the hard pancreas group. For durometer measurements, a correlation analysis showed a positive correlation with the ductal diameter and the duct-to-pancreas ratio and a negative correlation with ADC values.

CONCLUSION

Hard pancreases showed lower ADC values, a wider pancreatic duct diameter and a higher duct-to-pancreas ratio than soft pancreases. Additionally, the ADC values, diameter of the pancreatic duct and duct-to-pancreas ratio were closely correlated with the durometer results.

Radiofrequency ablation for liver metastases in patients with gastric cancer as an alternative to hepatic resection

Background

The purpose of this retrospective study was to determine whether RFA could provide an alternative treatment modality for selected patients who are not candidates for hepatic resection.

Methods

A total of 18 consecutive patients with liver metastases alone from gastric cancer treated with radiofrequency ablation (RFA, n = 11) or hepatic resection (HR, n = 7) at Seoul St. Mary’s Hospital, Korea, between January 2000 and September 2014, were enrolled.

Results

The median OS and DFS in the RFA group were 40.5 ± 22.3 and 10.3 ± 1.07 months, respectively. There was no significant difference between the RFA and HR groups in terms of baseline characteristics except for performance status. Mean survival and DFS times of all patients were 60.1 ± 9.4 and 40.9 ± 10.2 months, respectively. Mean OS times in the HR and RFA groups were 67.5 ± 15.4 and 51.1 ± 9.8 months (P = 0.671), respectively, and the mean DFS time in the HR group (74.1 ± 14.2 months) was longer than that in the RFA group (26.9 ± 9.2 months), but the difference was not significant (P = 0.076).

Conclusions

In patients who are not candidates for surgical treatment, RFA may be an alternative to HR.

Impact of body fat and muscle distribution on severity of acute pancreatitis

BACKGROUND/OBJECTIVES

Obesity is a well-established risk factor for severe acute pancreatitis (AP); however, the impact of visceral obesity or sarcopenic obesity on severity of AP has not been well studied. We compared the relationship between severity of AP and various body parameters including body weight, body mass index (BMI), subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), and visceral fat-to-muscle ratio (VMR).

METHODS

We analyzed the data of patients who were diagnosed with AP from 2009 to 2015. Image analysis software program (Aquarius Workstation software) was used to calculate individual VAT, SAT, and skeletal muscle areas from abdominal computed tomography scans at L3 vertebral levels. Revised Atlanta Classification was adopted to define severity of AP. Receiver operating characteristics (ROC) curves were constructed to determine the optimal threshold for predicting the severity.

RESULTS

Among 203 patients, 13 (6.4%) patients had severe AP and 62 (30.5%) patients had moderately severe cases. VMR demonstrated the highest area under the ROC curve [0.757, (95% confidence interval: 0.689-0.825)] in predicting moderately severe or severe AP. The optimal threshold of VMR for predicting severity was 1. The prevalence of various local complications and persistent organ failure were higher in patients with VMR over 1.

CONCLUSIONS

High visceral fat with low skeletal muscle volume was strongly correlated with AP severity. VMR had a stronger correlation with AP severity than body weight or BMI. This simple grading system would be useful if incorporated into future predictive scoring models.

Impact of preoperative sarcopenia and accelerated muscle loss on survival after resection of pancreatic cancer

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Background: Sarcopenia and accelerated muscle loss leading to cachexia is commonly observed in patients with pancreatic cancer. This study aimed to assess the influence of sarcopenia and accelerated skeletal muscle on survival in pancreatic cancer patients who underwent surgery. Methods: We analyzed the data of patients who were diagnosed with pancreatic adenocarcinoma who underwent surgery from 2008 to 2015. Skeletal muscle areas and changes were analyzed from two sets of computed tomography images at L3 vertebral levels obtained before and after resection of cancer. Sarcopenia was determined by the sex-specific cut-offs by an international consensus on the definition of cancer cachexia. Results: Among 175 patients, 83(47.4%) had preoperative sarcopenia and median survival were significantly shorter than patients without sarcopenia (423 vs. 694 days, p = 0.001). In addition, 50 (28.6%) patients with accelerated muscle loss after surgery ( > 15%/90 days) showed poorer survival compared with the patients without accelerated muscle loss (423 vs. 637 days, p = 0.017). Sarcopenia (hazard ratio [HR], 1.96: 95% confidence interval [CI], 1.24-3.10) and accelerated muscle loss (HR, 1.73: 95% CI, 1.10-2.72) were identified as independent predictors of survival on multivariate analyses. Combining these two factors, patients who had both preoperative sarcopenia and accelerated muscle loss showed the poorest survival after surgery compared with the other groups (p < 0.001). Conclusions: Preoperative sarcopenia and accelerated muscle loss identified by CT scans have negative impact on survival after resection of pancreatic cancer. Early detection and intensive nutritional support were essential for cachexic patients with pancreatic cancer.

Factors Related to Radiation Exposure during Lumbar Spine Intervention

Fluoroscopy guidance is useful to confirm anatomical landmark and needle location for spine intervention; however, it can lead to radiation exposure in patients, physicians, and medical staff. Physicians who used fluoroscopy should be cognizant of radiation exposure and intend to minimize radiation dose. We retrospectively reviewed three lumbar spine intervention procedures (nerve root block, medial branch block, and facet joint block) at our institution between June and December, 2014. We performed 268 procedures on 220 patients and found significant difference in radiation dose between two groups classified by performing physicians. The physician who controlled the fluoroscopy unit directly used significantly shorter fluoroscopy (6 seconds) that resulted in a smaller radiation dose (dose area product [DAP] 0.59 Gy∙cm(2)) than the physician supervising the radiographer controlling the fluoroscopy unit (72 seconds, DAP 5.31 Gy∙cm(2), P < 0.001). The analysis indicates that the difference in fluoroscopy time depends on whether a physician or a radiographer controls the fluoroscopy unit.

Diffusion-weighted imaging: Apparent diffusion coefficient histogram analysis for detecting pathologic complete response to chemoradiotherapy in locally advanced rectal cancer

PURPOSE

To investigate the usefulness of apparent diffusion coefficient (ADC) values derived from histogram analysis of the whole rectal cancer as a quantitative parameter to evaluate pathologic complete response (pCR) on preoperative magnetic resonance imaging (MRI).

MATERIALS AND METHODS

We enrolled a total of 86 consecutive patients who had undergone surgery for rectal cancer after neoadjuvant chemoradiotherapy (CRT) at our institution between July 2012 and November 2014. Two radiologists who were blinded to the final pathological results reviewed post-CRT MRI to evaluate tumor stage. Quantitative image analysis was performed using T2 -weighted and diffusion-weighted images independently by two radiologists using dedicated software that performed histogram analysis to assess the distribution of ADC in the whole tumor.

RESULTS

After surgery, 16 patients were confirmed to have achieved pCR (18.6%). All parameters from pre- and post-CRT ADC histogram showed good or excellent agreement between two readers. The minimum, 10th, 25th, 50th, and 75th percentile and mean ADC from post-CRT ADC histogram were significantly higher in the pCR group than in the non-pCR group for both readers. The 25th percentile value from ADC histogram in post-CRT MRI had the best diagnostic performance for detecting pCR, with an area under the receiver operating characteristic curve of 0.796.

CONCLUSION

Low percentile values derived from the ADC histogram analysis of rectal cancer on MRI after CRT showed a significant difference between pCR and non-pCR groups, demonstrating the utility of the ADC value as a quantitative and objective marker to evaluate complete pathologic response to preoperative CRT in rectal cancer. J. Magn. Reson. Imaging 2016;44:212-220.

Acute pulmonary complications in patients with hematologic malignancies

Various acute pulmonary complications may occur in patients with hematologic malignancies because they are in an immunocompromised state due to systemic disease or to chemotherapy or hematopoietic stem cell transplantation. Pulmonary complications may arise from other treatment regimens, as well, or from direct pulmonary involvement in the malignant disease process. The differential diagnosis of pulmonary opacities in patients with hematologic malignancies is broad and includes both infectious and noninfectious causes. Pulmonary hemorrhage, edema, leukostasis, and pneumonia are well-known and common acute pulmonary complications. Less common complications are now encountered with increasing frequency because of the increasing complexity of therapeutic regimens for hematologic malignancies, which may include various drugs that are in clinical trials or were recently released to market. These once uncommon acute pulmonary complications include retinoic acid syndrome, tyrosine kinase inhibitor-induced pulmonary complications, engraftment syndrome, and hemophagocytic lymphohistiocytosis. It is often difficult to differentiate between these entities. However, the clinical setting and radiologic imaging findings may provide clues for interpreting imaging findings of abnormal pulmonary opacity in patients with a hematologic malignancy. Pulmonary hemorrhage is characterized by a sudden onset of symptoms and rapid progression of pulmonary imaging abnormalities and usually occurs in patients with impaired coagulation or a predisposition to bleed. Pulmonary edema should be considered when typical findings of hydrostatic pulmonary edema are seen. Pulmonary leukostasis develops in patients with hyperleukocytosis and leads to symptoms such as a cough, fever, and dyspnea. Various types of pneumonia may develop, depending on the degree and duration of immunosuppression in the patient. Retinoic acid syndrome, tyrosine kinase inhibitor-induced pulmonary complications, and engraftment syndrome occur after specific treatments, so a detailed medical history including recent or current treatments may be helpful for diagnosis. Accurate differentiation of these entities allows their appropriate management, with resultant decreases in morbidity and mortality.