Improved diagnosis of well-differentiated hepatocellular carcinoma with gadolinium ethoxybenzyl diethylene triamine pentaacetic acid-enhanced magnetic resonance imaging and Sonazoid contrast-enhanced ultrasonography

AIM

  Two new imaging modalities have been developed recently that are directed at the focal liver lesions: gadolinium ethoxybenzyl diethylene triamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) and Sonazoid contrast-enhanced ultrasonography (CEUS). We investigated the usefulness of these modalities for the diagnosis of small (<2 cm), well-differentiated hepatocellular carcinoma (HCC).

METHODS

  A total of 15 nodules from 13 patients, which were histologically diagnosed as well-differentiated HCC, were subjected to this study. Lesions that showed hypervascularity in the arterial phase and washout in the portal or late non-hemodynamic phase were regarded as HCC in the dynamic studies of all imaging modalities.

RESULTS

  By multidetector computed tomography (MDCT), six of 15 (40%) nodules were diagnosed as HCC. Gd-EOB-DTPA-enhanced MRI diagnosed HCC in nine of the 15 (60%) nodules. Of the nine nodules that were not diagnosed by MDCT, four could be diagnosed by Gd-EOB-DTPA-enhanced MRI. In Sonazoid CEUS, 10 of 15 nodules (67%) were diagnosed as HCC. Four of nine nodules that could not be diagnosed as HCC by MDCT, were diagnosed by Sonazoid CEUS. A total of 11 of the 15 (73%) nodules were diagnosed as HCC by Gd-EOB-DTPA-enhanced MRI and Sonazoid CEUS in addition to MDCT.

CONCLUSION

  Gd-EOB-DTPA-enhanced MRI and Sonazoid CEUS had greater diagnostic value for small, well-differentiated HCC than did conventional MDCT.

Abstract 4580: Detection of early-stage pancreatic cancer by mass spectrometry: a multi-institutional validation study

Background Invasive ductal carcinoma of the pancreas is one of the worst prognoses among common human malignancies. The poor outcome of pancreatic cancer patients seems to be attributable to difficulty in early detection.

Methods Mass spectra of peptide were obtained from a total of 1314 plasma/serum samples, consisting 4 cohorts (namely Cohorts 1-4) obtained from 7 medical institutions participating in the “Third-Term Comprehensive Control Research for Cancer” conducted by the Ministry of Health, Labor and Welfare of Japan and one institute in Germany using orthogonal matrix assisted laser/desorption ionization time of flight (oMALDI-qQTOF-MS). The amino acid sequences and posttranslational modifications of marker proteins were identified by tandem mass spectrometry (MS/MS).

Results Plasma apolipoprotein AII heterodimer (ApoAII-2; 17252 m/z), unglycosylated apolipoprotein CIII (ApoCIII-0; 8766 m/z), and their summated value differed between 112 pancreatic cancer patients and 103 healthy controls (Cohort 1) with high statistical significance [P = 1.36 × 10−21, P = 4.35 × 10−14, and P = 1.83 × 10−24 (Mann-Whitney U-test)] and area-under-curve (AUC) values of 0.877, 0.798, and 0.903, respectively. The significance was further verified in 2 retrospective cohorts [Cohort 2 (n = 103) and Cohort 3 (n = 163)] and a hospital-based prospective cohort [Cohort 4 (n = 833)]. Patients with invasive ductal adenocarcinoma of the pancreas, including those with stage-I disease, could be discriminated from healthy controls with the sensitivity of 97.6% (243/249) and specificity of 95.3% (122/128) by the combination of DUPAN-2, CA19-9, ApoAII-2, and ApoCIII-0.

Interpretation Although the reduction of the 2 modified forms of plasma/serum apolipoproteins was not pancreatic cancer-specific, the accurate measurement of plasma/serum proteins had a high capability in detecting pancreatic cancer. This test is essentially safe and might be applicable to the primary mass screening of pancreatic cancer in asymptomatic populations.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 4580.

Slight dilatation of the main pancreatic duct and presence of pancreatic cysts as predictive signs of pancreatic cancer: a prospective study

PURPOSE

To prospectively determine whether slight dilatation of the main pancreatic duct and pancreatic cysts detected at ultrasonography (US) are predictive signs of pancreatic cancer.

MATERIALS AND METHODS

The research protocol was approved by the institutional review board, and written informed consent was obtained from all participants. One thousand fifty-eight subjects (age range, 36-80 years; mean, 61.8 years) with various kinds of abnormal US findings in the pancreas were enrolled from 1999 to 2002, after exclusion of pancreatic neoplasm and other malignant diseases. The endpoint was the subsequent development of pancreatic cancer, and the outcome was determined at the end of December 2007. To identify independent predictive variables for the subsequent development of pancreatic cancer, various baseline characteristics were examined by using a Cox regression model and a Cox proportional hazards model. The cumulative incidence of pancreatic cancer was estimated by using the Kaplan-Meyer method.

RESULTS

During the mean follow-up of 75.5 months (+/- 17.3[standard deviation]), pancreatic cancer subsequently developed in 12 of 1058 subjects. The risk of pancreatic cancer was significantly elevated in subjects with slight dilatation (> or = 2.5 mm) of the main pancreatic duct or presence of cyst (s) (> or = 5 mm). The respective hazard ratios were 6.38 (P = .018) and 6.23 (P = .003). For subjects with both findings, the 5-year cumulative risk of pancreatic cancer was 5.62% (95% confidence interval: .37%, 13.03%), and the age-and sex-adjusted hazard ratio compared with the risk in the absence of these findings was 27.50 (P = .002).

CONCLUSION

Main pancreatic duct dilatation (> or = 2.5 mm) and presence of a pancreatic cyst (> or = 5 mm) were both strong independent predictors of the subsequent development of pancreatic cancer. (c) RSNA, 2010.

Prolyl 4-hydroxylation of alpha-fibrinogen: a novel protein modification revealed by plasma proteomics

Plasma proteome analysis requires sufficient power to compare numerous samples and detect changes in protein modification, because the protein content of human samples varies significantly among individuals, and many plasma proteins undergo changes in the bloodstream. A label-free proteomics platform developed in our laboratory, termed "Two-Dimensional Image Converted Analysis of Liquid chromatography and mass spectrometry (2DICAL)," is capable of these tasks. Here, we describe successful detection of novel prolyl hydroxylation of alpha-fibrinogen using 2DICAL, based on comparison of plasma samples of 38 pancreatic cancer patients and 39 healthy subjects. Using a newly generated monoclonal antibody 11A5, we confirmed the increase in prolyl-hydroxylated alpha-fibrinogen plasma levels and identified prolyl 4-hydroxylase A1 as a key enzyme for the modification. Competitive enzyme-linked immunosorbent assay of 685 blood samples revealed dynamic changes in prolyl-hydroxylated alpha-fibrinogen plasma level depending on clinical status. Prolyl-hydroxylated alpha-fibrinogen is presumably controlled by multiple biological mechanisms, which remain to be clarified in future studies.

A multicenter randomized phase II study of full-dose gemcitabine and concurrent radiotherapy comparing gemcitabine alone for the unresectable locally advanced pancreatic adenocarcinoma

e15512

Background: Some of locally advanced pancreatic cancers (LAPC) are considered to include a potential micro metastasis. We think that full-dose of gemcitabine (GEM) improve the outcome of LAPC. We report the efficacy of full-dose GEM and concurrent radiotherapy, comparing GEM alone for unresectable LAPC. Methods: Patients with histologically or cytologically proven pancreatic adenocarcinoma were eligible for this study. We decide that LAPA which involved a major artery with CT imaging was unresectable. Patients were randomized into a concurrent chemoradiotherapy (CRT) group and a chemotherapy alone (CTX) group. GEM was given intravenously at a dose of 1,000 mg/msq over 30 min on days 1, 8 and 15 of each 28-day cycle and repeated until disease progression in both groups. Patients randomized into CRT group received a limited field irradiation with a total dose of 50 Gy in 25 sessions during first two cycles. The two groups were compared for mean survival, progression free survival and safety. Results: From September 2002 to April 2005, 80 patients were randomized at two institutions into the two arms of the trial (40 patients to CRT group and 40 patients to CTX group). The CRT group had better results than the CTX group as measured by mean survival time (391 vs 372 days, P< 0.02) and progression free survival (237 vs 128 days, P< 0.01). There were no differences in the safety between both groups. Conclusions: The concurrent chemoradiotherapy with full-dose GEM is effective and feasible in patients of LAPC compared with full-dose GEM alone.

No significant financial relationships to disclose.

Hypertension induced by erythropoietin has a correlation with truncated erythropoietin receptor mRNA in endothelial progenitor cells of hemodialysis patients

Endothelial nitric oxide (NO) and cyclic guanosine monophosphate (cGMP) contribute to erythropoietin (EPO)-induced hypertension, a major adverse reaction associated with EPO therapy. To investigate the mechanism of EPO-induced hypertension, we examined circulating endothelial progenitor cells (EPCs) taken from 56 hemodialysis (HD) patients. Among these EPCs (which reflect the condition of the endothelium), we looked for EPO receptor (EPOR) mRNAs. A truncated form of EPOR acts as a dominant negative regulator of EPO signaling, leading to hypertension. We found that the ratio of truncated EPOR mRNA in EPCs has a correlation with EPO-induced increase in blood pressure (r = 0.36, P = 0.02). The ratio of truncated to total EPOR mRNA in EPCs had an inverse correlation with EPO-induced cGMP production in vitro (r = -0.31, P = 0.02). A similar correlation was observed in cultured human endothelial cells after transfection of the full-length or truncated forms of EPOR (r = -0.92, P < 0.001). It follows, therefore, that evaluation of EPOR isoform mRNA in EPCs can predict EPO-induced hypertension. The termination of the EPO signal by truncated EPORs may decrease NO/cGMP production after EPO exposure, thereby raising blood pressure.

Practical prognostic index for patients with metastatic pancreatic cancer treated with gemcitabine

AIM

The aim of this study was to identify factors that predict treatment outcome in patients with metastatic pancreatic cancer treated with gemcitabine, and then to use these factors to develop a practical prognostic index.

METHODS

A retrospective study was performed on 66 consecutive patients with histologically confirmed pancreatic adenocarcinoma who were treated with gemcitabine. Factors that predicted treatment outcome were identified by univariate and multivariate analyses using the Cox proportional hazards model.

RESULTS

Multivariate analysis identified Eastern Cooperative Oncology Group performance status, primary tumor location, and C-reactive protein as important independent predictive factors. Prognostic score was calculated using the following formula: score = (1 if performance status is 0 or 1; 2 if performance status is 2; and 5 if performance status is 3) + (1 if primary site is body or tail, 3 if primary site is head) + (1 if C-reactive protein is <1 mg/dL, 3 if C-reactive protein is 1-3 mg/dL, 6 if C-reactive protein is >3 mg/dL). Patients were accordingly divided into three groups: good (prognostic index = 3 or 4), fair (prognostic index = 5-7), and poor (prognostic index = 8). Median survival was 265, 155, and 65 days for each group, respectively (P < 0.0001). The internally validated c-index (receiver operating characteristics area under the curve) of this model was 0.711. Applied to another data set, the externally validated c-index was 0.692. Prognosis was favorable in the good prognosis group, patients in the fair prognosis group were likely to benefit from gemcitabine, and those in the poor prognosis group were unlikely to benefit.

CONCLUSION

This index improved predictive ability in patients with metastatic pancreatic cancer treated with gemcitabine, which may be helpful in counseling patients and making first treatment decisions.

Concurrent chemoradiotherapy for advanced pancreatic cancer: 1,000 mg/m2 gemcitabine can be administered using limited-field radiotherapy

PURPOSE

To examine the feasibility of concurrent use of full-dose gemcitabine (GEM) and radiotherapy for advanced pancreatic cancer.

PATIENT AND METHODS

22 patients with advanced pancreatic cancer were subjected to concurrent chemoradiotherapy (GEM 1,000 mg/m(2) weekly, three times during 4 weeks). They received limited-field irradiation by three-dimensional radiotherapy planning.

RESULTS

Of the 22 patients, 16 (72%) completed the treatment (50 Gy irradiation and at least three times concurrent administration of 1 g/m(2) GEM). One patient with unresectable tail cancer showed peritonitis carcinomatosa and both chemotherapy and radiotherapy had to be stopped. Dose reduction or omission of GEM was necessary in another four patients. In addition, radiotherapy was discontinued in one patient for fatigue. Grade 3 hematologic toxicity was detected in eight patients (36%), and grade 3 nonhematologic toxicity (anorexia) in one patient (5%). In total, the response rate amounted to 32% (seven partial responses), and the median survival time (MST) was 16 months. Among the twelve patients who received preoperative chemoradiotherapy, nine underwent surgery and showed a survival rate of 78% at 1 year. Another 13 patients without surgery showed 14 months of MST. No regional lymph node failure has appeared so far.

CONCLUSION

Limited-field radiotherapy enables the safe concurrent administration of 1,000 mg/m(2) GEM.

Indoxyl sulfate stimulates proliferation of rat vascular smooth muscle cells

Vascular smooth muscle cell (VSMC) proliferation is a key event in the progression of arteriosclerosis. Clinical studies show that uremic toxins deteriorate the arteriosclerosis in renal failure patients. Indoxyl sulfate (IS) is a strong protein-bound uremic toxin, but the effect of IS on VSMC proliferation has not been studied. We examined the effect of IS on rat VSMC proliferation, assessed by a cell counting kit (4-[3-[4-lodophenyl]-2-4(4-nitrophenyl)-2H-5-tetrazolio-1,3-benzene disulfonate] assay) and by [(3)H]thymidine incorporation in vitro. We further evaluated a contribution of mitogen-activated protein kinase (MAPK; p44/42 MAPK) to VSMC proliferation by IS. Immunohistochemical staining was performed for VSMCs using antirat organic anion transporter (OAT)3 antibody. The mRNA expressions of platelet-derived growth factor (PDGF)-A and -C chains, and PDGF-beta receptor were evaluated by real-time PCR. IS stimulated the proliferation of VSMCs in a concentration-dependent manner and activated p44/42 MAPK. Concentration of IS needed to stimulate the proliferation of rat VSMC was about 250 microM, which is compatible with that in the serum of end-stage renal failure patients. PD98059 (10 microM), a selective inhibitor of MAPK/extracellular signal-regulated kinase, inhibited the IS-induced (250 microM) VSMC proliferation and phosphorylation of MAPK. Probenecid (0.5 mM), an inhibitor and substrate of OAT, inhibited the IS-induced (250 microM) VSMC proliferation. Rat OAT3 was detected in VSMCs. The mRNA expressions of PDGF-C chain and PDGF-beta receptor were significantly increased by IS. We conclude that IS directly stimulates rat VSMC proliferation and activates MAPK in vitro. This might be one of the mechanisms underlying the progression of atherosclerotic lesions in end-stage renal disease patients.

Periodic ultrasonography checkup for the early detection of pancreatic cancer: preliminary report

OBJECTIVES

To introduce our new ultrasonography (US) system for early detection of pancreatic cancer and report its preliminary results.

METHODS

The basis of the system is periodic checkups for high-risk patients. Abnormal US findings, such as main pancreatic duct dilatation or pancreatic cyst(s), were indicated as high risk. Special US focusing on the pancreas and a set of serum tests were performed every 3 or 6 months. When some development was detected, additional examinations, including ERP with pancreatic juice cytology, were performed. There were 1098 subjects admitted through the end of May 1998, and the outcomes of these subjects were followed through the end of March 2002.

RESULTS

Three hundred ninety-three patients were registered for the periodic checkups. Pancreatic ductal adenocarcinoma was detected in 44 patients: 41 by the initial examination and 3 by the periodic checkups. Surgical resection was performed in 40.9%, and 50% of the resected patients were in stages 0-III. The cumulative 3-year survival rates of the resected patients were 100% in stages 0 and III, 75% in stage I, and 33% in stage IVa.

CONCLUSION

Periodic US checkups for patients with main pancreatic duct dilatation or cyst(s) are considered to be an effective method for the early detection of pancreatic cancer.

Reduction in salivary cortisol level by music therapy during colonoscopic examination

BACKGROUND/AIMS

Premedication for endoscopy promotes patient cooperation and makes subsequent examinations more acceptable. Music therapy is widely used in the treatment of acute and chronic pain. Therefore, we investigated the effects of music therapy on pain and on salivary cortisol levels in patients undergoing screening colonoscopy.

METHODOLOGY

The subjects were 29 consecutive patients undergoing colonoscopy for various reasons. Patients were randomly assigned to undergo colonoscopy while listening to music (n=15) or while not listening to music (n=14). Cortisol levels were measured in samples of saliva obtained before and after colonoscopy. After colonoscopy, patients were asked to rate their maximum pain during colonoscopy.

RESULTS

Patients who listened to music during colonoscopy tended to have lower pain scores. Salivary cortisol levels increased significantly less in the group receiving music.

CONCLUSIONS

Music therapy during colonoscopy markedly reduces fear-related stress, as indicated by changes in salivary cortisol levels.

Study of Prevention of Colorectal Cancer through Lifestyle Modification: an Introduction to the Protocol

Previous epidemiological studies have suggested that lack of exercise and a high fat diet increase the risk of colorectal cancer. We planned a clinical trial to test these propositions, using subjects with multiple colorectal adenomas and/or carcinomas. Enrolment in this study was conducted in two stages. First, patients were invited to participate in the dietary modification part of the study. Those agreeing to participate were given dietary advice, and 3 months later all subjects to whom the exercise exclusion criteria do not apply were invited to participate in the exercise part of the study. The subjects were randomized to two groups. A total of two hundred and eleven patients meeting the entry criteria have been invited to join the trial, of whom 165 (78%) consented to participate in the dietary modification part of the study. After excluding those unsuitable according to the exclusion criteria for the exercise regimen, the remaining 124 subjects were further invited to participate in the exercise regimen part of the study. One hundred and three (83%) subjects have given their consent. Obtaining informed consent in two stages and the free provision of lifestyle modification measures were factors that contributed to this favorable participation rate.

Main pancreatic duct dilatation: a sign of high risk for pancreatic cancer

BACKGROUND

The prognosis of pancreatic ductal adenocarcinoma remains very poor, but is better in patients with a small tumor without local infiltration. The identification of the sign of high risk for pancreatic cancer will lead to early detection and improvement of the prognosis of this disease. The purpose of this study was to evaluate the main pancreatic duct dilatation as a sign of high risk for pancreatic cancer.

METHODS

The diameter of the main pancreatic duct was measured by ultrasonography. The proportion of cases with main pancreatic duct dilatation was retrospectively examined in a pre-cancer group (39 subjects in whom pancreatic cancer developed more than 1 year later and surgically resected) and in a control group (10 244 subjects). Then the proportions in both groups were compared using the odds ratio.

RESULTS

The proportion of cases with a slight dilatation (>/=2 mm in diameter) of the main pancreatic duct was 65% in the pre-cancer group, more than 4 years before the resection of the pancreatic cancer. In contrast, it was 5.35% in the age-matched control subjects. The odds ratio of 32.5 (95% confidence interval: 10.9-107.3) shows a significant association between the main pancreatic duct dilatation and the pre-cancer condition. Moreover, the proportion and the mean diameter of the dilated duct in the pre-cancer group increased with time.

CONCLUSION

Slight dilatation of the main pancreatic duct appears to be a sign of high risk for pancreatic cancer. The systematic examination of high-risk subjects is recommended for the early detection of pancreatic cancer.

Dynamic sonography of pancreatic tumors: comparison with dynamic CT

OBJECTIVE

The aim of this study was to examine the usefulness of dynamic sonography in the characterization of pancreatic tumors.

MATERIALS AND METHODS

IV contrast-enhanced pancreatic sonography (dynamic sonography) with Levovist was performed in 43 patients with pancreatic mass lesions (32 with pancreatic adenocarcinomas, four with inflammatory pancreatic masses, three with islet cell tumors, two with serous cystadenomas, one with a solid and cystic tumor, and one with metastatic pancreatic cancer). We calculated a contrast index using a time-intensity curve: contrast index equals elevation of intensity in the tumor divided by elevation of intensity in the pancreatic parenchyma. We classified the tumors into three groups according to the contrast index: a slightly enhanced group (contrast index < 0.5), a moderately enhanced group (contrast index = 0.5-1.5), and a well-enhanced group (contrast index > 1.5), and we compared these results with those from dynamic CT.

RESULTS

The contrast indexes of 32 adenocarcinomas, four inflammatory pancreatic masses, three islet cell tumors, two serous cystadenomas, one solid and cystic tumor, and one metastatic tumor were, respectively, 0.12 +/- 0.095 (mean +/- SD), 0.54 +/- 0.420, 1.74 +/- 0.555, 1.09 +/- 1.380, 1.67, and 2.07. Thirty-five tumors, including all 32 adenocarcinomas, were classified in the slightly enhanced group, three were classified in the moderately enhanced group, and five were classified in the well-enhanced group. In 93% (40/43) of tumors, the grade of enhancement on dynamic sonography was closely correlated with the grade of enhancement on dynamic CT.

CONCLUSION

Dynamic sonography can assist in the characterization of pancreatic tumors.

Association between plasma lipoprotein(a) and endothelial dysfunction in normocholesterolemic and non-diabetic patients with angiographically normal coronary arteries

The present study was designed to examine whether elevated levels of lipoprotein(a) (Lp(a)) are related to the impairment of the endothelium-dependent vasoresponse to acetylcholine (ACh) in normocholesterolemic and non-diabetic human normal coronary arteries. ACh (30 microg) was injected into the left main coronary artery of 31 patients (serum low-density cholesterol <160mg/dl and fasting plasma glucose <126mg/dl) with angiographically normal coronary arteries, and the relation between diameter change and lipid levels was analyzed. The mean diameter change of all coronary segments examined (segments 6, 8, 11 and 13) was reduced by 14.6+/-26.5% in response to ACh, but increased by 23.3+/-6.0% in response to nitroglycerin, suggesting endothelial dysfunction in those arteries. The mean diameter change of the left anterior descending artery or left circumflex artery in each patient was negatively correlated only with the level of Lp(a). Stepwise multiple regression analysis also revealed that only Lp(a) among the lipids showed significant correlation with impaired vasodilation (p=0.033). These findings suggest that elevated levels of plasma Lp(a) might be a strong predictor of endothelial dysfunction in normocholesterolemic and non-diabetic subjects.

Chlamydia pneumoniae infection and accelerated development of coronary artery disease in patients with chronic renal failure

AIMS

This study examined the relationship between Chlamydia pneumoniae (C. pneumoniae) infection and the accelerated development of coronary artery disease (CAD) in patients with chronic renal failure (CRF).

METHODS

Two-hundred and fourteen patients undergoing coronary angiography, including 67 controls and 147 patients with CAD (97 without CRF and 50 with CRF), were enrolled in this study. Anti-C. pneumoniae specific IgG and IgA antibodies were measured using an enzyme-linked immunosorbent assay (ELISA).

RESULTS

Coronary artery disease (expressed as CAD score) was more severe in patients with than without CRF (14.9 +/- 6.0 vs. 11.3 +/- 6.0, p < 0.01). Seropositive rates of IgG and IgA antibodies against C. pneumoniae were higher in all CAD patients than in the controls (76.2% vs. 44.8%, p < 0.001 for IgG; 59.9% vs. 40.3%, p < 0.01 for IgA). In both CAD subgroups, IgG seropositive rates were similarly elevated (82.0% and 73.2% vs. 44.8% for control, p < 0.001, respectively), whereas those of IgA were significantly elevated only in CAD with CRF (68.0% vs. 55.7% for control, p < 0.01). The mean antibody index of IgG was elevated in all CAD patients compared with the controls (1.9 +/- 1.0 vs. 1.3 +/- 0.9, p < 0.0001), but that of IgA was not (1.5 +/- 1.0 vs. 1.2 +/- 0.9). Levels of IgG were elevated in all patients with CAD compared with the control (2.4 +/- 1.1 and 1.8 +/- 1.0 vs. 1.3 +/- 0.9, p < 0.001 and p < 0.001, respectively), whereas those of IgA were elevated only in CAD with CRF (1.8 +/- 1.1 vs. 1.2 +/- 0.9, p < 0.05). Stepwise logistic regression analysis revealed that the elevated IgG antibody index was an independent risk factor for CAD regardless of CRF (odds ratios 1.9, 1.8, and 2.3), whereas the IgA index was a risk factor only in CAD with CRF (odds ratio 1.7).

CONCLUSIONS

Chlamydia pneumoniae infection may be related to the accelerated CAD in patients with CRF, which was specifically suggested by an elevated IgA level. In other words, the prevalence of active C. pneumoniae infection is higher in patients with CAD and CRF than that in those with CAD without CRF.

Dynamic sonography of hepatic tumors

OBJECTIVE

Our objectives were to propose and evaluate a dynamic sonography protocol for the characterization of hepatic tumors.

SUBJECTS AND METHODS

The subjects were 107 patients with focal liver lesions that initially had been found on conventional sonograms. The final diagnoses for the lesions were hepatocellular carcinoma in 60 patients, cholangiocellular carcinoma in six, metastatic carcinoma in 24, hemangioma in 10, and focal fat-spared region in seven. The pulse inversion harmonic imaging mode and a galactose-based contrast agent (Levovist) were used. Dynamic sonography was designed to obtain vascular-phase (composed of the arterial phase and the portal phase) images of the focal lesion and liver-parenchymal-phase images of the whole liver in a series obtained after a bolus injection of the contrast agent.

RESULTS

If the whole-tumor or mosaic enhancement patterns (arterial phase) and/or the reticular enhancement (parenchymal phase) are regarded as positive findings for hepatocellular carcinoma, the sensitivity, specificity, and positive predictive value of dynamic sonography in our study were 92%, 96%, and 96%, respectively. If a ring enhancement (arterial to portal phase) or a clear defect (parenchymal phase) or both are regarded as positive findings for cholangiocellular carcinoma or metastasis, the sensitivity, specificity, and positive predictive value were 90%, 95%, and 88%, respectively. If puddle enhancement (portal phase) is regarded as a positive finding for hemangioma, the figures for sensitivity, specificity, and positive predictive value were 60%, 100%, and 100%, respectively. Also, the tumors that showed no focal sign in the liver parenchymal phase were all benign lesions, such as hemangiomas or focal fat-spared regions.

CONCLUSION

Dynamic sonography in a protocol combining pulse inversion harmonic imaging and an IV bolus injection of the contrast agent proved to be an effective tool in characterizing liver tumors.