Hepatic tumors: predisposing factors for complications of transcatheter oily chemoembolization

PURPOSE

To elucidate major complications and their predisposing factors in transcatheter oily chemoembolization (TOCE) for hepatic tumors.

MATERIALS AND METHODS

In a retrospective study of 351 patients (aged 26-82 years) with hepatic tumors, TOCE was performed 942 times with an emulsion of iodized oil (3-40 mL) and doxorubicin hydrochloride (20-60 mg). In 126 patients, TOCE was followed by absorbable gelatin sponge embolization.

RESULTS

Complications were severe postembolization syndrome (n = 53); hepatic insufficiency (n = 20), infarction (n = 1), or abscess (n = 1); intrahepatic biloma formation (n = 3); tumor rupture (n = 3); septicemia (n = 9); coagulopathy (n = 1); gastrointestinal bleeding (n = 10); gallbladder (n = 5) or splenic infarction (n = 4); pulmonary oil embolism (n = 6); and spinal cord injury (n = 1). Important predisposing factors were major portal vein obstruction, compromised hepatic functional reserve, biliary obstruction, previous biliary surgery, excessive amount (> 20 mL) of iodized oil, hepatic arterial occlusion after repeated TOCE, and nonselective embolization.

CONCLUSION

Most patients with major complications after TOCE had preexisting risk factors.

Preoperative staging of uterine cervical carcinoma: comparison of CT and MRI in 99 patients

OBJECTIVE

The aim of this study was to compare CT and MRI at 0.5 T in the preoperative staging of uterine cervical cancer in a large series of patients.

MATERIALS AND METHODS

Ninety-nine patients with uterine cervical carcinoma underwent CT, MRI, and surgical exploration.

RESULTS

Both CT and MR findings were compared using surgical-pathologic findings as gold standards. Magnetic resonance imaging was superior to CT in tumor detection (sensitivity 75 vs. 51%, p < 0.005), in parametrial evaluation (accuracy 87 vs. 80%, p < 0.005), in overall tumor staging (accuracy 77 vs. 69%, p < 0.025), and in pelvic lymph node evaluation (accuracy 88 vs. 83%, p < 0.01). Magnetic resonance imaging had an accuracy of 76% in assessment of the thickness of cervical stromal invasion.

CONCLUSION

Magnetic resonance imaging was superior to CT in preoperative staging of uterine cervical carcinoma and MRI should be used instead of CT for preoperative staging of this disease.

Aspirin versus clopidogrel for chronic maintenance monotherapy after percutaneous coronary intervention (HOST-EXAM): an investigator-initiated, prospective, randomised, open-label, multicentre trial

BACKGROUND

Optimal antiplatelet monotherapy during the chronic maintenance period in patients who undergo coronary stenting is unknown. We aimed to compare head to head the efficacy and safety of aspirin and clopidogrel monotherapy in this population.

METHODS

We did an investigator-initiated, prospective, randomised, open-label, multicentre trial at 37 study sites in South Korea. We enrolled patients aged at least 20 years who maintained dual antiplatelet therapy without clinical events for 6-18 months after percutaneous coronary intervention with drug-eluting stents (DES). We excluded patients with any ischaemic and major bleeding complications. Patients were randomly assigned (1:1) to receive a monotherapy agent of clopidogrel 75 mg once daily or aspirin 100 mg once daily for 24 months. The primary endpoint was a composite of all-cause death, non-fatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and Bleeding Academic Research Consortium (BARC) bleeding type 3 or greater, in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT02044250.

FINDINGS

Between March 26, 2014, and May 29, 2018, we enrolled 5530 patients. 5438 (98·3%) patients were randomly assigned to either the clopidogrel group (2710 [49·8%]) or to the aspirin group (2728 [50·2%]). Ascertainment of the primary endpoint was completed in 5338 (98·2%) patients. During 24-month follow-up, the primary outcome occurred in 152 (5·7%) patients in the clopidogrel group and 207 (7·7%) in the aspirin group (hazard ratio 0·73 [95% CI 0·59-0·90]; p=0·0035).

INTERPRETATION

Clopidogrel monotherapy, compared with aspirin monotherapy during the chronic maintenance period after percutaneous coronary intervention with DES significantly reduced the risk of the composite of all-cause death, non-fatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and BARC bleeding type 3 or greater. In patients requiring indefinite antiplatelet monotherapy after percutaneous coronary intervention, clopidogrel monotherapy was superior to aspirin monotherapy in preventing future adverse clinical events.

FUNDING

ChongKunDang, SamJin, HanMi, DaeWoong, and the South Korea Ministry of Health and Welfare.

Hepatic tumors: contrast agent-enhancement patterns with pulse-inversion harmonic US

PURPOSE

To evaluate contrast agent-enhancement patterns in hepatic hemangiomas, hepatic metastases, and hepatocellular carcinomas (HCCs) at pulse-inversion harmonic ultrasonography (US) with a microbubble contrast agent.

MATERIALS AND METHODS

Twenty hepatic hemangiomas in 20 patients and 41 malignant hepatic tumors in 23 patients (33 metastases and eight HCCs) were evaluated with pulse-inversion harmonic US. US images were obtained before injection and every 10-15 seconds after injection of a 4-g bolus (300 mg/mL) of SH U 508A (a microbubble contrast agent) for 5 minutes. The contrast-enhancement patterns of 61 hepatic lesions were assessed.

RESULTS

Of 20 hemangiomas, 19 revealed peripheral enhancement, which was globular in 14 (70%) and rimlike in five (25%), with centripetal fill-in; the remaining one (5%) showed homogeneous enhancement. In 33 metastases, the enhancement was rimlike in 16 (48%), homogeneous in seven (21%), and stippled in two (6%); in the remaining eight metastases (24%), no enhancement was seen. Of eight HCCs, four (50%) showed homogeneous enhancement and the remaining four (50%) showed heterogeneous enhancement. Centripetal fill-in of lesions with intratumoral enhancement was not seen in any malignancy.

CONCLUSION

Pulse-inversion harmonic US with a microbubble contrast agent is potentially useful for the specific diagnosis of hemangiomas that demonstrate characteristic enhancement features.

Nontumorous arterioportal shunt mimicking hypervascular tumor in cirrhotic liver: two-phase spiral CT findings

PURPOSE

To determine the two-phase (hepatic arterial phase [HAP] and portal venous phase [PVP]) spiral computed tomographic (CT) findings of a nontumorous arterioportal shunt in the cirrhotic liver that can mimic a hypervascular tumor.

MATERIALS AND METHODS

For 14 months, 803 patients with known or suspected hepatocellular carcinoma were referred for initial or repeated transcatheter arterial chemoembolization (TACE). Twenty-nine hyperattenuating lesions on HAP CT images obtained in 25 patients (23 men, two women; age range, 39-70 years) were regarded as nontumorous arterioportal shunts and were included in this study. The diagnosis of nontumorous arterioportal shunt was established by four radiologists who reviewed the two-phase spiral CT images and hepatic angiograms.

RESULTS

The longest dimension of the lesion was 1.0-7.9 cm (mean dimension, 2.9 cm). The morphology at HAP CT was wedge-shaped in 25 (86%), geographic (ie, focal area with irregular outline) in two (7%), and nodular in two (7%) lesions. All lesions were homogeneous in attenuation. Hyperattenuating linear branching structures that represented early opacification of portal veins were demonstrated during the HAP in nine (31%) lesions. PVP CT images showed these lesions as isoattenuating (n = 20 [69%]) or slightly hyperattenuating (n = 9 [31%]). Iodized oil CT images showed faint or no accumulation of iodized oil in all lesions.

CONCLUSION

In cirrhotic liver, nontumorous arterioportal shunts can be a cause of pseudolesions that mimic hypervascular tumors at two-phase spiral CT. Lesions that have the typical wedge-shaped and homogeneous appearance with or without internal linear branching structures during the HAP and that are isoattenuating or slightly hyperattenuating during the PVP can suggest this unusual condition.

Prasugrel-based de-escalation of dual antiplatelet therapy after percutaneous coronary intervention in patients with acute coronary syndrome (HOST-REDUCE-POLYTECH-ACS): an open-label, multicentre, non-inferiority randomised trial

BACKGROUND

A potent P2Y12 inhibitor-based dual antiplatelet therapy is recommended for up to 1 year in patients with acute coronary syndrome receiving percutaneous coronary intervention (PCI). The greatest benefit of the potent agent is during the early phase, whereas the risk of excess bleeding continues in the chronic maintenance phase. Therefore, de-escalation of antiplatelet therapy might achieve an optimal balance between ischaemia and bleeding. We aimed to investigate the safety and efficacy of a prasugrel-based dose de-escalation therapy.

METHODS

HOST-REDUCE-POLYTECH-ACS is a randomised, open-label, multicentre, non-inferiority trial done at 35 hospitals in South Korea. We enrolled patients with acute coronary syndrome receiving PCI. Patients meeting the core indication for prasugrel were randomly assigned (1:1) to the de-escalation group or conventional group using a web-based randomisation system. The assessors were masked to the treatment allocation. After 1 month of treatment with 10 mg prasugrel plus 100 mg aspirin daily, the de-escalation group received 5 mg prasugrel, while the conventional group continued to receive 10 mg. The primary endpoint was net adverse clinical events (all-cause death, non-fatal myocardial infarction, stent thrombosis, repeat revascularisation, stroke, and bleeding events of grade 2 or higher according to Bleeding Academic Research Consortium [BARC] criteria) at 1 year. The absolute non-inferiority margin for the primary endpoint was 2·5%. The key secondary endpoints were efficacy outcomes (cardiovascular death, myocardial infarction, stent thrombosis, and ischaemic stroke) and safety outcomes (bleeding events of BARC grade ≥2). The primary analysis was in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT02193971.

RESULTS

From Sept 30, 2014, to Dec 18, 2018, 3429 patients were screened, of whom 1075 patients did not meet the core indication for prasugrel and 16 were excluded due to randomisation error. 2338 patients were randomly assigned to the de-escalation group (n=1170) or the conventional group (n=1168). The primary endpoint occurred in 82 patients (Kaplan-Meier estimate 7·2%) in the de-escalation group and 116 patients (10·1%) in the conventional group (absolute risk difference -2·9%, p_{non-inferiority}<0·0001; hazard ratio 0·70 [95% CI 0·52-0·92], p_equivalence=0·012). There was no increase in ischaemic risk in the de-escalation group compared with the conventional group (0·76 [0·40-1·45]; p=0·40), and the risk of bleeding events was significantly decreased (0·48 [0·32-0·73]; p=0·0007).

INTERPRETATION

In east Asian patients with acute coronary syndrome patients receiving PCI, a prasugrel-based dose de-escalation strategy from 1 month after PCI reduced the risk of net clinical outcomes up to 1 year, mainly driven by a reduction in bleeding without an increase in ischaemia.

FUNDING

Daiichi Sankyo, Boston Scientific, Terumo, Biotronik, Qualitech Korea, and Dio.

Therapeutic effect of transcatheter oily chemoembolization therapy for encapsulated nodular hepatocellular carcinoma: CT and pathologic findings

An emulsion of iodized oil and doxorubicin hydrochloride was intraarterially injected in 27 patients with encapsulated single nodular hepatocellular carcinoma (HCC). Computed tomography (CT) was performed 1-3 weeks after injection, and the lesions were resected 1-4 weeks thereafter. The percentages of tumor necrosis were evaluated in cut surfaces of resected specimens and were compared with the findings at iodized-oil CT. Six tumors with complete intratumor retention of iodized oil had 98% necrosis, and 21 tumors with incomplete retention had 64% necrosis. Two tumors with complete retention of iodized oil in the surrounding liver had 100% necrosis, while 16 tumors with partial retention and nine tumors without retention of iodized oil in surrounding liver had 74% and 62% necrosis, respectively. Complete retention of iodized oil in the tumor and surrounding liver demonstrated the best therapeutic effects. Evaluation of the pattern and distribution of iodized oil in the tumor and surrounding liver with iodized-oil CT is useful in the assessment of the therapeutic effects of transcatheter arterial embolization in encapsulated nodular HCCs.

Liver abscess after transcatheter oily chemoembolization for hepatic tumors: incidence, predisposing factors, and clinical outcome

PURPOSE

To evaluate the incidence of, predisposing factors for, and clinical outcome of liver abscess developing in patients with hepatic tumors after transcatheter oily chemoembolization (TOCE).

MATERIALS AND METHODS

During the past 6-year period, 2,439 patients with hepatic tumors underwent a total of 6,255 TOCE procedures. With a retrospective review of medical records, the authors evaluated the occurrence of liver abscess, the statistical significance of potential predisposing factors including portal vein obstruction, metastatic tumors, biliary abnormalities (type 1, simple biliary obstruction; type 2, status prone to ascending biliary infection), malignant gastrointestinal mucosal lesions, and additional gelatin sponge particle embolization in liver abscess formation, and the clinical outcome of abscess.

RESULTS

Fifteen liver abscesses occurred in 14 patients (0.2%). Liver abscesses developed in three of 987 (0.3%) TOCE procedures for portal vein obstruction, three of 114 (2.6%) procedures for metastatic tumors, one of 49 (1.8%) for type 1 biliary abnormality, four of 55 (7.4%) for type 2 biliary abnormality, two of 18 (11.1%) for malignant gastrointestinal mucosal lesion, and nine of 2,108 (0.4%) for additional gelatin sponge particle embolization. Univariate and multivariate statistical analysis showed that type 2 biliary abnormality was a significant predisposing factor. The mortality related to liver abscess occurred in two patients (13.3%). Thirteen liver abscesses were successfully treated with parenteral antibiotics and percutaneous catheter drainage. However, irreversible deterioration of liver function occurred in two patients. Two of nine further TOCE procedures in three patients caused recurrent septicemia and liver abscess.

CONCLUSION

The biliary abnormality prone to ascending biliary infection was the most important predisposing factor to the development of liver abscess after TOCE. Postembolic liver abscess could be effectively managed with percutaneous catheter drainage.

Power versus conventional color Doppler sonography: comparison in the depiction of vasculature in liver tumors

PURPOSE

To compare power and conventional color Doppler sonography in the depiction of the intratumoral vasculature of hemangiomas, hepatocellular carcinomas (HCCs), and metastases of the liver.

MATERIALS AND METHODS

Thirty-two patients with liver tumors (12 hemangiomas, 11 HCCs, and nine metastases) were prospectively evaluated with power and conventional color Doppler sonography by using a 2-4-MHz convex probe with 2-MHz Doppler frequency. Power Doppler sonography was performed with a 75%-88% gain. Conventional color Doppler sonography was performed with a 55%-75% gain and a pulse repetition frequency of 700 Hz. Power Doppler signals and color Doppler signals interrogated in one plane were analyzed by two radiologists, who subjectively rated power Doppler sonography as superior, equal, or inferior to color Doppler sonography.

RESULTS

Overall, power Doppler sonography was superior to color Doppler sonography in 18 patients and equal in 14 (P < .01). In hemangiomas, power Doppler sonography was superior to color Doppler sonography in 10 patients and equal in two (P < .01). In HCCs, power Doppler sonography was superior to color Doppler sonography in four patients and equal in seven (P > .05). In metastases, power Doppler sonography was superior to color Doppler sonography in four patients and equal in five (P < .05).

CONCLUSION

Power Doppler sonography is more sensitive than color Doppler sonography in the depiction of the vasculature of liver tumors, particularly in hemangiomas.

An evolution in the management of sinonasal inverting papilloma

OBJECTIVE

We reviewed the 15-year experience of our institution (Medical College of Wisconsin, Milwaukee, WI) in managing sinonasal inverting papilloma, examining trends in diagnosis and treatment.

STUDY DESIGN

Retrospective.

METHODS

Thirty-seven patients with inverting papilloma were treated from 1986 to 1999. Demographic data, clinical presentations, pathological findings, surgical approaches and procedures, and recurrence rates were collected retrospectively. Each lesion was categorized into one of four groups based on computed tomography scans and endoscopic findings. This categorization was developed to compare various surgical approaches for tumors in each group.

RESULTS

Thirty-one patients had complete information for inclusion in our study. Nineteen patients were treated endoscopically with an average follow-up of 50 months. Eight patients were in group I, five were in group II, six were in group III, and no patients were in group IV. The recurrence rate for the endoscopic group was 10%. Twelve patients underwent lateral rhinotomy or sublabial degloving approach with an average follow-up of 58 months. Five patients were in group I, three patients were in group II, 1 patient was in group III, and three patients were in group IV. The recurrence rate for the external group was 8%. Difference in recurrence rates (P =.85) was not observed between the endoscopic and external approach groups. Regardless of approach, patients who had primary resection had a recurrence of 0%, whereas those with secondary resection had a recurrence of 17% (P =.10).

CONCLUSIONS

Technological advancements have led to a trend of detecting sinonasal inverting papilloma before extension beyond the sinonasal region. Difference in recurrence rates was not observed between the endoscopic and the external approach groups. Recurrence rates are lower for primary resection versus secondary resection, regardless of surgical approach.

Hepatocellular carcinoma and portal vein invasion: results of treatment with transcatheter oily chemoembolization

OBJECTIVE

Our objective was to evaluate the efficacy and safety of transcatheter oily chemoembolization therapy in a series of patients with hepatocellular carcinoma and portal vein invasion.

MATERIALS AND METHODS

We retrospectively analyzed the results of transcatheter oily chemoembolization for 110 patients with hepatocellular carcinoma invading major portal branches. The Child's classes were A for 94 patients and B for 16. The main portal vein was partially (n = 33) or completely (n = 15) invaded in 48 patients, the right portal vein was invaded in 36, and the left portal vein was invaded in 26. Oily chemoembolization was performed with an emulsion of iodized oil and doxorubicin hydrochloride. Gelatin sponge particle embolization was added for 78 patients. Seventy-one patients underwent multiple treatment sessions.

RESULTS

Our initial findings showed that 31 patients had complete or partial remission, with an overall median survival time of 6 months. The cumulative survival rates were 48% (6 months), 30% (1 year), 18% (2 years), and 9% (3 years). The parenchymal tumor extent was the most significant predicting factor for complications and efficacy of therapy. Of 33 patients with a parenchymal tumor limited to one or two segments of a hepatic lobe, 22 had complete or partial remission, with a median survival time of 22 months; this survival time was significantly longer than that (5 months) for 77 patients with a more extensive tumor (p < .0001). Hepatic insufficiency developed in 10 patients, and three of them died within 1 month after chemoembolization. All 10 patients had an extensive parenchymal tumor involving more than two hepatic segments, and four had impaired hepatic functional reserve of Child's class B.

CONCLUSION

When a tumor is limited in extent and hepatic function is preserved, transcatheter oily chemoembolization is effective and safe for the palliation of hepatocellular carcinoma and major portal vein invasion. However, when a parenchymal tumor is extensive, chemoembolization is associated with a poor response and a risk of hepatic failure.

Peripheral cholangiocarcinoma of the liver: two-phase spiral CT findings

PURPOSE

To determine characteristic features of peripheral cholangiocarcinoma on two-phase spiral computed tomographic (CT) scans.

MATERIALS AND METHODS

Thirty-four patients with peripheral cholangiocarcinoma underwent two-phase spiral CT. Hepatic arterial phase and portal venous phase images were obtained 30 and 65 seconds, respectively, after the start of contrast material infusion.

RESULTS

Thin, mild, incomplete rimlike contrast enhancement at the tumor periphery was seen on CT scans from both phases in 23 patients. Thick, continuous rimlike contrast enhancement and marked homogeneous contrast enhancement were present on scans in four patients and one patient, respectively. No definite contrast enhancement pattern was seen on scans in six patients. Other findings included increased lobar or segmental hepatic attenuation in adjacent normal liver during the arterial phase (n = 10), markedly low attenuation with amorphous areas of slightly high attenuation in the tumor during both phases (n = 33), internal septumlike linear structures (n = 8), narrowing or obstruction of the portal vein as it traversed the tumor (n = 16), and a patent hepatic vein (n = 4).

CONCLUSION

Thin, mild, incomplete rimlike contrast enhancement at the tumor periphery and markedly low intratumoral attenuation with amorphous areas of slightly high attenuation during both scanning phases are typical findings of peripheral cholangiocarcinoma.

Pulmonary oil embolism after transcatheter oily chemoembolization of hepatocellular carcinoma

The medical records of 336 patients with hepatocellular carcinoma who underwent transcatheter oily chemoembolization (TOCE) performed via the hepatic artery were retrospectively reviewed to ascertain the occurrence of symptomatic pulmonary oil embolism. In 14 patients, more than 20 mL of iodized oil was administered. In six of these 14 patients, respiratory symptoms of cough, hemoptysis, and dyspnea developed 2-5 days after TOCE, and their chest radiographs showed diffuse bilateral pulmonary parenchymal infiltrate. Their arterial partial pressure of oxygen while they breathed room air ranged from 39 to 60 mm Hg during maximum hypoxemia. The symptoms, arterial hypoxemia, and chest radiographic abnormalities completely cleared 10-28 days after TOCE in the five patients who survived. One patient died 10 days after TOCE because of respiratory arrest with a progression of pulmonary infiltrate. Although histopathologic proof is lacking, it is concluded that massive pulmonary embolization of iodized oil was the primary cause of the clinical and radiographic manifestations in these six patients.

Transcatheter oily chemoembolization of the inferior phrenic artery in hepatocellular carcinoma: the safety and potential therapeutic role

PURPOSE

To evaluate the efficacy and safety of transcatheter oily chemoembolization therapy (TOCE) via the inferior phrenic artery (IPA) in hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Fifty patients with HCC underwent a total of 82 procedures of TOCE of the IPA, as well as of the hepatic artery. In 16 patients, additional extrahepatic collaterals were depicted and were also embolized in 10 patients. TOCE was performed with an emulsion of iodized oil and doxorubicin hydrochloride, and gelatin sponge particle embolization was added in 32 patients.

RESULTS

Initial response showed complete or partial remission of the tumor in 31 patients. The cumulative survival rates after combined TOCE of the hepatic artery, IPA, and other extrahepatic arteries were 89% (6 months), 78% (1 year), 46% (2 year), and 30% (3 year), when calculated from the time of IPA chemoembolization. Liver abscess and empyema developed in one case of combined IPA and multiple intercostal artery chemoembolization. There were no serious complications after IPA chemoembolization alone.

CONCLUSION

TOCE of the IPA has a potential therapeutic role as a safe adjunct to TOCE of the hepatic artery in the management of HCC supplied by the IPA.

Hepatocellular carcinoma: power Doppler US with a contrast agent--preliminary results

PURPOSE

To investigate the value of contrast material-enhanced power Doppler ultrasonography (US) in the demonstration and characterization of tumor vascularity in hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Twenty patients with HCC were prospectively evaluated with power Doppler US before and after injection of the contrast agent SH U 508 A. The grade and pattern of tumor vascularity at power Doppler US were analyzed, along with the degree of tumor staining at angiography.

RESULTS

Intra- and peritumoral flow signals were detected in 19 HCCs (95%) at unenhanced power Doppler US. After injection of contrast agent, flow signals increased in 19 lesions (95%). At contrast-enhanced power Doppler US, two tumors demonstrated grade 1 vascularity; four, grade 2; three, grade 3; and 11, grade 4. At angiography, two tumors demonstrated grade 1 staining; four, grade 2; eight, grade 3; and six, grade 4. The correlation between vascularity grades at contrast-enhanced power Doppler US and at angiography was statistically significant (P < .0001). Seventeen HCCs (85%) showed the intratumoral or basket pattern of vascularity at unenhanced power Doppler US; after injection of contrast material, 15 HCCs (75%) showed the mixed pattern.

CONCLUSION

Contrast-enhanced power Doppler US is superior to unenhanced power Doppler US in the demonstration and characterization of tumor vascularity in HCC.

Abdominal amyloidosis: spectrum of radiological findings

Amyloidosis is a disease characterized by the deposition of fibrillar protein amyloid of beta-structure in organs or tissues. It is usually classified as either a primary disease or secondary to a co-existent condition, such as rheumatoid arthritis, tuberculosis, or neoplasm (particularly multiple myeloma or renal cell carcinoma). Amyloid protein deposition can be seen in a variety of organs though it occurs with higher frequency in the gastrointestinal tract, kidney, and heart. Amyloidosis can have a wide spectrum of manifestations in nearly every abdominal organ. Some of these, for example, multiple cystic submucosal masses of the stomach, amyloidosis of the gallbladder, and dirty soft tissue infiltration of the subcutaneous fat, have not yet been covered in the radiological literature. The combination of various imaging techniques and the identification of characteristic computed tomography (CT) hepatic features may help in the differentiation of amyloidosis from other infiltrative diseases; however, confirmative diagnosis can usually only be achieved by tissue biopsy.

Vascularity of hepatocellular carcinoma: assessment with contrast-enhanced second-harmonic versus conventional power Doppler US

PURPOSE

To compare contrast material-enhanced harmonic power Doppler ultrasonography (US) with conventional power Doppler US in depicting the vascularity of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Twenty patients with nodular HCCs (2.6-13.2 cm in diameter; mean diameter, 4.8 cm) were prospectively examined with both conventional and harmonic power Doppler US. US was performed with a 2-4-MHz curved linear-array transducer according to a standard examination protocol (1,000-Hz pulse repetition frequency, medium wall filter, and power gain of 55%-84% for conventional power Doppler US; 700-Hz pulse repetition frequency, low wall filter, and power gain of 95%-98% for harmonic power Doppler US). Serial, dynamic scans were obtained before intravenous injection of the contrast agent (SH U 508A) and at 30, 60, 90, 120, 180, 240, and 300 seconds after injection with both techniques.

RESULTS

The number of intratumoral power Doppler US signals was similar with both techniques at 30-90 seconds after contrast agent injection; however, after 90 seconds, conventional power Doppler US depicted significantly more signals than did harmonic power Doppler US. Harmonic power Doppler US was superior to conventional power Doppler US in terms of power Doppler artifacts such as "blooming" or motion-related artifacts.

CONCLUSION

Although the effective enhancement duration is relatively short compared with that for conventional power Doppler US, contrast-enhanced harmonic power Doppler US can be effective in evaluating the vascularity of HCCs because of the advantage of fewer power Doppler artifacts.

Direct Conversion of Adult Skin Fibroblasts to Endothelial Cells by Defined Factors

Background—

Cell-based therapies to augment endothelial cells (ECs) hold great therapeutic promise. Here, we report a novel approach to generate functional ECs directly from adult fibroblasts.

Methods and Results—

Eleven candidate genes that are key regulators of endothelial development were selected. Green fluorescent protein (GFP)–negative skin fibroblasts were prepared from Tie2-GFP mice and infected with lentiviruses allowing simultaneous overexpression of all 11 factors. Tie2-GFP + cells (0.9%), representing Tie2 gene activation, were detected by flow cytometry. Serial stepwise screening revealed 5 key factors (Foxo1, Er71, Klf2, Tal1, and Lmo2) that were required for efficient reprogramming of skin fibroblasts into Tie2-GFP + cells (4%). This reprogramming strategy did not involve pluripotency induction because neither Oct4 nor Nanog was expressed after 5 key factor transduction. Tie2-GFP + cells were isolated using fluorescence-activated cell sorting and designated as induced ECs (iECs). iECs exhibited endothelium-like cobblestone morphology and expressed EC molecular markers. iECs possessed endothelial functions such as Bandeiraea simplicifolia -1 lectin binding, acetylated low-density lipoprotein uptake, capillary formation on Matrigel, and nitric oxide production. The epigenetic profile of iECs was similar to that of authentic ECs because the promoters of VE-cadherin and Tie2 genes were demethylated. mRNA profiling showed clustering of iECs with authentic ECs and highly enriched endothelial genes in iECs. In a murine model of hind-limb ischemia, iEC implantation increased capillary density and enhanced limb perfusion, demonstrating the in vivo viability and functionality of iECs.

Conclusions—

We demonstrated the first direct conversion of adult fibroblasts to functional ECs. These results suggest a novel therapeutic modality for cell therapy in ischemic vascular disease.

Wnt signaling exerts an antiproliferative effect on adult cardiac progenitor cells through IGFBP3

RATIONALE

Recent work in animal models and humans has demonstrated the presence of organ-specific progenitor cells required for the regenerative capacity of the adult heart. In response to tissue injury, progenitor cells differentiate into specialized cells, while their numbers are maintained through mechanisms of self-renewal. The molecular cues that dictate the self-renewal of adult progenitor cells in the heart, however, remain unclear.

OBJECTIVE

We investigate the role of canonical Wnt signaling on adult cardiac side population (CSP) cells under physiological and disease conditions.

METHODS AND RESULTS

CSP cells isolated from C57BL/6J mice were used to study the effects of canonical Wnt signaling on their proliferative capacity. The proliferative capacity of CSP cells was also tested after injection of recombinant Wnt3a protein (r-Wnt3a) in the left ventricular free wall. Wnt signaling was found to decrease the proliferation of adult CSP cells, both in vitro and in vivo, through suppression of cell cycle progression. Wnt stimulation exerted its antiproliferative effects through a previously unappreciated activation of insulin-like growth factor binding protein 3 (IGFBP3), which requires intact IGF binding site for its action. Moreover, injection of r-Wnt3a after myocardial infarction in mice showed that Wnt signaling limits CSP cell renewal, blocks endogenous cardiac regeneration and impairs cardiac performance, highlighting the importance of progenitor cells in maintaining tissue function after injury.

CONCLUSIONS

Our study identifies canonical Wnt signaling and the novel downstream mediator, IGFBP3, as key regulators of adult cardiac progenitor self-renewal in physiological and pathological states.

Enhancement patterns of hepatocellular carcinomas on multiphasicmultidetector row CT: comparison with pathological differentiation

OBJECTIVE

The objective of this study was to determine the incidence of typical and atypical enhancement patterns of hepatocellular carcinomas (HCCs) on multiphasic multidetector row CT (MDCT) and to correlate the enhancement patterns and morphological image findings of HCC with the degree of tumour differentiation.

METHODS

MDCT images of 217 patients with 243 surgically proven HCCs were evaluated through consensus reading by two radiologists. Our MDCT protocol was composed of precontrast, arterial, portal and delayed phases. The reviewers analysed the CT images for degree of attenuation; relative timing of washout; presence of dysmorphic intratumoral vessels, aneurysms and necrosis; tumour size; tumour margin; presence of pseudocapsule; intratumoral heterogeneity; and determined enhancement pattern. The imaging features were correlated with tumour differentiation using Fisher's exact test or the χ(2) test.

RESULTS

Among 243 HCCs, 137 (56.4%) showed the typical enhancement pattern of HCC, which is arterial enhancement and washout on portal or equilibrium phase images. In the arterial phase, 190 of 243 (78.2%) HCCs showed hypervascularity, with approximately three quarters of poorly differentiated (PD) (34 of 45, 75.6%) and moderately differentiated (MD) HCCs (92 of 123, 74.8%) showing washout during the portal or delayed phases, vs only 50% of well-differentiated (WD) HCCs (11 of 22; p<0.048). The presence of intratumoral vessels and aneurysms, tumour necrosis, attenuation of precontrast, the relative timing of washout, intratumoral attenuation heterogeneity, tumour margin and tumour size were correlated with the pathological differentiation of HCCs (p<0.05).

CONCLUSION

A typical enhancement of HCCs on MDCT was not unusual (43.6%) and WD and PD HCCs account for most of the atypical enhancement patterns. Early washout favoured MD and PD HCCs rather than WD HCCs, whereas in our study the presence of intratumoral aneurysm was a highly specific finding for PD HCC.

Comparison among drug-eluting balloon, drug-eluting stent, and plain balloon angioplasty for the treatment of in-stent restenosis: a network meta-analysis of 11 randomized, controlled trials

OBJECTIVES

A Bayesian network meta-analysis was performed comparing the efficacy and safety of drug-eluting balloons (DEB), drug-eluting stents (DES), or plain old balloon angioplasty (POBA) for treatment of in-stent restenosis (ISR).

BACKGROUND

Optimal treatment options for ISR have not been well established.

METHODS

Randomized, controlled trials comparing DEB, DES, and POBA for the treatment of ISR after percutaneous coronary intervention with bare metal stent or DES were included. The primary outcome was target lesion revascularization (TLR). The pairwise posterior median odds ratio (OR) with 95% credible interval (CrI) was the effect measure.

RESULTS

This analysis included 2,059 patients from 11 RCTs. The risk of TLR was markedly lower in patients treated with DEB (OR: 0.22, 95% CrI: 0.10 to 0.42) or DES (OR: 0.24, 95% CrI: 0.11 to 0.47) than in those treated with POBA in a random-effects model. In a comparison of DEB and DES, the risk of TLR (OR: 0.92, 95% CrI: 0.43 to 1.90) was similar. The risk of MI or all-cause mortality was lowest in the DEB group compared with the DES and POBA groups, which did not meet statistical significance. The risk of major adverse cardiac events, which was mainly driven by TLR, was also significantly lower in the DEB or and DES group (OR: 0.28, 95% CrI: 0.14 to 0.53) than in the POBA group, but it was similar between the DEB and DES groups (OR: 0.84, 95% CrI: 0.45 to 1.50). The probability of being ranked as the best treatment was 59.9% (DEB), 40.1% (DES), and 0.1% (POBA) in terms of TLR, whereas it was 63.0% (DEB), 35.3% (POBA), and 1.7% (DES) in terms of MI.

CONCLUSIONS

Local drug delivery by DEB or DES for ISR lesions was markedly better than POBA in preventing TLR, but not for MI or mortality. Among the 2 different strategies of drug delivery for ISR lesions, treatment with DEB showed a trend of less development of MI than did treatment with DES.

Unusual gastric tumors: radiologic-pathologic correlation

The overlap of radiologic findings in many gastric tumors makes differentiation difficult. However, some unusual gastric tumors have characteristic radiologic features that may suggest a specific diagnosis. At barium study, lipomas typically manifest as a smooth submucosal mass or an ulcerated lesion with a "bull's-eye" appearance that is indistinguishable from other mesenchymal tumors. At computed tomography (CT), lipomas usually manifest as well-circumscribed submucosal masses with fat attenuation. At radiology, glomus tumors appear as smooth submucosal masses with or without ulceration and may contain tiny flecks of calcification. These tumors frequently demonstrate strong enhancement on early-phase contrast material-enhanced images. At barium study, lymphangiomas may appear as smooth intramural masses that are indistinguishable from other mesenchymal tumors. At CT, they manifest as non-enhancing extramucosal masses with homogeneous low attenuation. Diffuse lesions in Brunner gland hamartoma manifest as multiple small nodules, producing a characteristic "cobblestone" appearance. Lymphomas may have typical imaging features (eg, more pronounced and homogeneous mural thickening) that can help differentiate them from adenocarcinoma. In addition, adenocarcinomas may demonstrate unusual findings such as transpyloric spread, unusually large polyps, or intratumoral calcifications. Familiarity with these radiologic features of gastric tumors can help ensure correct diagnosis and proper management.

Streptococcus milleri: an organism for head and neck infections and abscess

BACKGROUND

Streptococcus milleri, a commensal organism, has the potential to cause significant morbidity. There is a paucity of published data regarding this organism in the head and neck.

OBJECTIVES

To identify and assess the presentation, treatment, and outcomes of pediatric patients affected by this pathogen.

STUDY DESIGN

Review of the Department of Pathology database at Children's Hospital of Wisconsin, Milwaukee, between 1997 and 1999 identified 26 patients with cultures positive for S milleri group (SMG) bacteria. Retrospective chart analysis examined the demographic data, site of origin of infection, additional organisms cultured, symptoms, treatments, and complications.

RESULTS

Sixteen patients had SMG infections involving the head and neck region. Sites of origin included the paranasal sinuses, dental, facial soft tissues, deep neck spaces, peritonsillar region, and a tracheostomy site. The paranasal sinuses were the most common site in 37% (6/16). Streptococcus milleri was the only isolate in 69% (11) of the infections. Significant local extension occurred in 56% (9/16) of the patients and included the orbit, skull base, cranium, and deep neck spaces. All patients had surgical drainage and 15 also received intravenous antibiotic treatment. One complication of osteomyelitis of the frontal bone occurred with resolution after surgical debridement and intravenous antibiotic treatment.

CONCLUSIONS

Streptococcus milleri can be an aggressive pathogen in the head and neck with a propensity for abscess formation and local extension of the infection in a pediatric population. Surgical drainage with antibiotics is generally successful in management of the condition. However, emerging penicillin resistance and the ability for local extension require suspicion of incomplete treatment if clinical symptoms persist.

CT features of intraductal intrahepatic cholangiocarcinoma

OBJECTIVE

The objective of this report was to describe the CT features of intraductal intrahepatic cholangiocarcinoma.

CONCLUSION

Segmental or lobar dilatation of the intrahepatic bile ducts associated with or without intraductal polypoid mass, amorphous structures, or both with slight hyperattenuation are common CT findings of intraductal intrahepatic cholangiocarcinoma. The size of the intraductal mass determines the visibility on CT.