Ultrasound tissue scatterer distribution imaging: An adjunctive diagnostic tool for shear wave elastography in characterizing focal liver lesions

OBJECTIVES

Focal liver lesion (FLL) is a prevalent finding in cross-sectional imaging, and distinguishing between benign and malignant FLLs is crucial for liver health management. While shear wave elastography (SWE) serves as a conventional quantitative ultrasound tool for evaluating FLLs, ultrasound tissue scatterer distribution imaging (TSI) emerges as a novel technique, employing the Nakagami statistical distribution parameter to estimate backscattered statistics for tissue characterization. In this prospective study, we explored the potential of TSI in characterizing FLLs and evaluated its diagnostic efficacy with that of SWE.

METHODS

A total of 235 participants (265 FLLs; the study group) were enrolled to undergo abdominal examinations, which included data acquisition from B-mode, SWE, and raw radiofrequency data for TSI construction. The area under the receiver operating characteristic curve (AUROC) was used to evaluate performance. A dataset of 20 patients (20 FLLs; the validation group) was additionally acquired to further evaluate the efficacy of the TSI cutoff value in FLL characterization.

RESULTS

In the study group, our findings revealed that while SWE achieved a success rate of 49.43 % in FLL measurements, TSI boasted a success rate of 100 %. In cases where SWE was effectively implemented, the AUROCs for characterizing FLLs using SWE and TSI stood at 0.84 and 0.83, respectively. For instances where SWE imaging failed, TSI achieved an AUROC of 0.78. Considering all cases, TSI presented an overall AUROC of 0.81. There was no statistically significant difference in AUROC values between TSI and SWE (p > 0.05). In the validation group, using a TSI cutoff value of 0.67, the AUROC for characterizing FLLs was 0.80.

CONCLUSIONS

In conclusion, ultrasound TSI holds promise as a supplementary diagnostic tool to SWE for characterizing FLLs.

Nasopharyngeal carcinoma patient-derived xenograft mouse models reveal potential drugs targeting cell cycle, mTOR, and autophagy pathways

BACKGROUND

Nasopharyngeal carcinoma (NPC) is associated with Epstein-Barr virus (EBV) infection. To test preclinical NPC drugs, we established two patient-derived xenograft (PDX) mouse models, EBV-positive PDX-B13 and EBV-negative PDX-Li41, for drug screening.

METHODS

Based on next generation sequencing (NGS) studies, PDX-B13 had CCND1 copy number (CN) gain but CDKN2A CN loss, whereas PDX-Li41 had CDKN2A and RB1 CN loss, TSC1 (negative regulator of mTOR) frameshift deletion mutation, and increased activation of mTOR, a serine/threonine kinase that governs metabolism, autophagy, and apoptosis. Increased mTOR was also associated with poor NPC prognosis.

RESULTS

Everolimus, an mTOR inhibitor, suppressed tumor growth in the two PDX NPC models and had an additive antitumor effect with palbociclib, a CDK4/6 inhibitor. PDX tumors treated with various drugs or untreated were subjected to RNA sequencing, transcriptome profile analysis, and selective Western blotting to understand the interactions between these drugs and gene expression profiles. Palbociclib also suppressed EB viral nuclear antigen (EBNA1) expression in PDX-B13. Everolimus together with autophagy inhibitor, hydroxychloroquine, had additive anti-tumor effect on PDX-B13 tumor. Immunohistochemistry revealed that high mTOR levels were correlated with poor overall survival in patients with metastatic NPC (N = 90).

CONCLUSIONS

High mTOR levels are a poor prognostic factor in NPC, and cell cycle, mTOR and autophagy pathways may serve as therapeutic targets in NPC. In addition, PDX models can be used for efficiently testing potential NPC drugs.

Dynamic Change of Albumin-Bilirubin Score Is Good Predictive Parameter for Prognosis in Chronic Hepatitis C-hepatocellular Carcinoma Patients Receiving Transarterial Chemoembolization

Background and Aims: The Albumin-Bilirubin (ALBI) grade is a good index for liver function evaluation and is also associated with the outcomes of hepatocellular carcinoma patients receiving TACE. However, the correlation between the dynamic change to the ALBI score and clinical outcome is seldom discussed. Therefore, this study aimed to investigate the application of ALBI grade and dynamic change of ALBI grade (delta ALBI grade) after first TACE for prognosis prediction in HCC patients with chronic hepatitis C infection. Method: From January 2005 to December 2015, newly diagnosed naive chronic hepatitis C-hepatocellular carcinoma (CHC-HCC) patients who were treated with TACE as the initial treatment at the Chang Gung Memorial Hospital, Linkou Medical Center, were retrospectively recruited. The pre-treatment host factors, tumor status and noninvasive markers were collected. The Cox regression model was used to identify independent predictors of overall survival and tumor recurrence. Results: Among 613 treatment-naive CHC-HCC patients, 430 patients died after repeated TACE during a median follow-up of 26.9 months. Complete remission after repeated TACE occurred in 46.2% patients, and 208 patients (33.9%) had tumor recurrence, with a median recurrence-free interval of 8.5 months. In Cox regression analysis, ALBI grade II/III (aHR: 1.088, p = 0.035) and increased delta ALBI grade (aHR: 1.456, p = 0.029) were independent predictive factors for tumor recurrence. Furthermore, ALBI grade II/III (aHR: 1.451, p = 0.005) and increased delta ALBI grade during treatment (aHR: 1.436, p = 0.006) were predictive factors for mortality, while achieving complete response after repeated TACE (aHR: 0.373, p < 0.001) and anti-viral therapy (aHR: 0.580, p = 0.002) were protective factors for mortality. Conclusion: Both ALBI and delta ALBI grade are independent parameters to predict survival and tumor recurrence of CHC-HCC patients receiving TACE treatment.

Complete response at first transarterial chemoembolization predicts favorable outcome in hepatocellular carcinoma

Transarterial chemoembolization (TACE) is the mainstay of treatment for patients with intermediate/advanced stage or unresectable hepatocellular carcinoma (HCC). Despite the palliative nature of TACE treatment, embolizing the tumor feeding vessels and leading to progressive tumor necrosis, complete response (CR) after TACE could still be observed in a certain population. Thus, this study aimed to investigate both the predictors for CR and the long-term prognosis of the patients with CR after TACE. The study recruited new diagnosed HCC patients initially treated with TACE from 2010 to 2013. Post TACE response was assessed by scheduled image studies according to the modified Response Evaluation Criteria in Solid Tumors (mRECIST). Then, pre-TACE factors were compared between patients with and without CR. After the first session of TACE, 22.3% of the 669 TACE treated patients achieved CR. During a median of 26.6 months follow-up, patients with CR had better overall survival than those without (median: 35.8 vs. 24.0 months, P<0.001). By multivariate logistic regression analysis, Child-Turcotte-Pugh class B (OR: 0.419, P=0.005), tumor burden beyond up-to-7 criteria (OR: 0.118, P<0.001), bilobar tumor extent (OR: 0.236, P<0.001), higher alpha-fetoprotein (AFP) level (≥20 ng/ml, OR: 0.614, P=0.039) and higher platelet counts (>150 k/μl, OR: 0.482, P=0.002) were unfavorable predictors for CR after first TACE. In addition, macrovascular invasion (HR: 3.113, P=0.001) and higher AFP levels (≥15 ng/ml, HR: 2.601, P=0.007) were predictors for early HCC recurrence whereas diabetes mellitus (DM) (HR: 2.166, P=0.006) was the only significant predictor for late HCC recurrence in CR patients. In conclusion, more than one-fifth of HCC patients achieved CR after first TACE and these patients had favorable prognosis. Furthermore, tailored post-TACE follow-up strategies shall be considered in patients with different risk factors of early or late recurrence after CR.

Prospective comparison of early interim 18F-FDG-PET with 18F-FLT-PET for predicting treatment response and survival in metastatic breast cancer

Background

To compare the value of interim ¹⁸F-FLT-PET and ¹⁸F-FDG-PET for predicting treatment outcomes in patients with metastatic breast cancer after salvage therapy.

Methods

Patients with metastatic breast cancer received PET/CT using ¹⁸F-FLT and ¹⁸F-FDG at baseline, after the 1st and 2nd cycle of systemic chemotherapy. The clinical response was classified according to Response Evaluation Criteria in Solid Tumors 1.1 based on contrast-enhanced CT after 3 months of systemic chemotherapy. The metabolic response on PET was assessed according to European Organization for Research and Treatment of Cancer criteria or PET Response Criteria in Solid Tumors (PERCIST) and was correlated to the clinical response, overall survival (OS), and progression-free survival (PFS).

Results

Twenty-five patients entered final analysis. On ¹⁸F-FDG-PET, clinical responders after 2 chemotherapy cycles (post-2c) had a significantly greater reduction of maximal standardized uptake value (SUV) and the peak SUV corrected for lean body mass (SULpeak) of the tumor than non-responders (P = 0.030 and 0.003). Metabolic response determined by PERCIST on post-2c ¹⁸F-FDG-PET showed a high area under the receiver operating characteristics curve of 0.801 in predicting clinical response (P = 0.011). Patients who were metabolic responders by PERCIST on post-2c ¹⁸F-FDG-PET had a significantly longer PFS (53.8% vs. 16.7%, P = 0.014) and OS (100% vs. 47.6%, P = 0.046) than non-responders. Survival differences between responders and non-responders in the interim ¹⁸F-FLT-PET were not significant.

Conclusions

¹⁸F-FLT-PET failed to show an advantage over ¹⁸F-FDG-PET in predicting the treatment response and survival in patients with metastatic breast cancer. Assessment of treatment outcome by interim ¹⁸F-FDG-PET may aid treatment.

Trial registration

The study was retrospectively registered on 02/06/2020 on Clinicaltrials.gov (identifier NCT04411966).

MELD score is the better predictor for 30-day mortality in patients with ruptured hepatocellular carcinoma treated by trans-arterial embolization

BACKGROUND AND AIMS

Spontaneous hepatocellular carcinoma (HCC) rupture is a catastrophic life-threatening complication that could be rescued by trans-arterial embolization (TAE). However, deteriorated liver function with total bilirubin more than 3 mg/dL was deemed as a relative contraindication. This study was aimed to re-evaluate this relative contraindication.

METHODS

Patients with ruptured HCC and treated by TAE between February 2005 and December 2016 in Chang Gung Memorial Hospital, Linkou branch were recruited. Pre-TAE characteristics including age, gender, etiology, liver biochemistry, Child-Pugh classification, Model for End-Stage Liver Disease (MELD) score, the presence of shock, tumor staging and post TAE liver function were compared between patients with and without post-TAE 30-day mortality.

RESULTS

A total of 186 patients were enrolled. The successful hemostatic rate after embolization was 91.4% and the median overall survival was 224 days. The 30-day cumulative mortality rate is 20.4%. By multivariate logistic regression analysis, male [aOR: 0.25, P=0.034] MELD score [aOR: 13.61, P<0.001], tumor size [aOR: 1.21, P=0.023] are the independent predictors for 30-day mortality. MELD score has better predictability of post-TAE 30-day mortality than total bilirubin level (AUROC: 0.818 vs. 0.668). The cut-off points of MELD score 13 has higher negative predictive value of 95% for post-TAE 30-day mortality.

CONCLUSION

TAE is effective for the initial hemostasis in patients with HCC rupture. MELD score ≥13 rather than only total bilirubin level >3 mg/dL be more predictive of post TAE 30-day mortality.

Combination of Epithelial Growth Factor Receptor Blockers and CDK4/6 Inhibitor for Nasopharyngeal Carcinoma Treatment

Simple Summary

Our findings indicated that the EGF-EGFR pathway was highly activated in very young patients with recurrent or metastatic NPC. High EGFR expression in patients with metastatic NPC resulted in poor clinical outcomes. To examine whether the EGFR pathway serves as a therapeutic target for NPC, NPC patient-derived xenograft (PDX) and NPC cell lines were treated with EGFR inhibitors (EGFRi) and a cell cycle blocker. Either EGFRi or cell cycle blocker treatment alone could reduce NPC cell growth and PDX tumor growth. Furthermore, combination treatment exerted an additive suppression effect on PDX tumor growth. This study provides promising evidence that EGFRi used in combination with a cell cycle blocker may be used to treat patients with NPC.

Abstract

Background: Nasopharyngeal carcinoma (NPC) involves host genetics, environmental and viral factors. In clinical observations, patients of young and old ages were found to have higher recurrence and metastatic rates. Methods: Cytokine array was employed to screen druggable target(s). The candidate target(s) were confirmed through patient-derived xenografts (PDXs) and a new EBV-positive cell line, NPC-B13. Results: Overexpression of epithelial growth factor (EGF) and EGF receptor (EGFR) was detected in young patients than in older patients. The growth of NPC PDX tumors and cell lines was inhibited by EGFR inhibitors (EGFRi) cetuximab and afatinib when used separately or in combination with the cell cycle blocker palbociclib. Western blot analysis of these drug-treated PDXs demonstrated that the blockade of the EGF signaling pathway was associated with a decrease in the p-EGFR level and reduction in PDX tumor size. RNA sequencing results of PDX tumors elucidated that cell cycle-related pathways were suppressed in response to drug treatments. High EGFR expression (IHC score ≥ grade 3) was correlated with poor survival in metastatic patients (p = 0.008). Conclusions: Our results provide encouraging preliminary data related to the combination treatment of EGFRi and palbociclib in patients with NPC.

Alpha-fetoprotein response at different time-points is associated with efficacy of nivolumab monotherapy for unresectable hepatocellular carcinoma

Nivolumab monotherapy has a modest objective response rate (ORR) in hepatocellular carcinoma (HCC). To overcome the lack of biomarkers that predict delayed alpha-fetoprotein (AFP) response beyond 4 weeks, we applied a novel 50-10 rule of AFP response for unresectable HCC patients under nivolumab monotherapy and proposed an algorithm based on on-treatment AFP reduction at different time-points. Ninety unresectable HCC patients who underwent nivolumab monotherapy in 2015-2019 were retrospectively recruited and divided into four classes: rapid AFP decrease of ≥ 50% of baseline at week 4 (class I), AFP changes within ± 50% of baseline at week 4 that later decreased to ≥ 10% of baseline (class II) or not (class III) at week 12, and rapid AFP increase of ≥ 50% of baseline at week 4 (class IV). ORR was 47.4%, 36.0%, 7.7%, and 5.0% in class I-IV patients, respectively. Rapid (class I) and delayed (class II) AFP responders had significantly higher ORR, overall survival (OS) and progression-free survival (PFS) than non-responders (class III and IV) (ORR: 40.9% vs. 6.5%, P<0.001; median OS: not reached vs. 9.6 months, log-rank P<0.001; median PFS: 9.6 vs. 2.8 months, log-rank P<0.001). In multivariate analysis, AFP response was an independent factor associated with good OS (hazard ratio [HR]=0.301, P=0.001) and PFS (HR=0.332, P<0.001). Moreover, AFP responders had higher ORR and better OS as well as PFS than non-responders, regardless of nivolumab as a first- or more than a second-line therapy (all P<0.05). In conclusion, the novel 50-10 rule of AFP response provides practical guidance for nivolumab monotherapy in unresectable HCC patients. However, this algorithm remains to be verified in a large prospective cohort.

Switching monopolar radiofrequency ablation improves long-term outcomes of medium-sized hepatocellular carcinoma

OBJECTIVES

Radiofrequency ablation (RFA) of medium-sized (3-5 cm) hepatocellular carcinoma (HCC) is suboptimal. Switching monopolar RFA (SW-RFA) enlarges the ablative volume to better cover larger tumors. This study aims to compare the long-term outcomes of medium-sized HCC treated by either SW-RFA or single-monopolar RFA (S-RFA).

METHODS

We retrospectively reviewed 139 cases (147 medium-size HCC) between 2008 and 2014. Under propensity score matching, a total of 43 paired patients with medium-size HCC and balanced clinical variables treated by either SW-RFA or S-RFA were selected for comparison.

RESULTS

SW-RFA showed a higher rate of achieving an adequate safety margin (p = 0.002). After a mean follow-up period of 40.4 months, SW-RFA produced significantly lower global RFA failure rates (p < 0.001) and better overall survival (p = 0.005) compared to S-RFA. SW-RFA was independently associated with a decreased risk of global RFA failure (hazard ratio [HR]: 0.136, 95% confidence interval [CI]: 0.030-0.607, p = 0.009) and improved overall survival (HR: 0.337, 95% CI: 0.152-0.747, p = 0.007). By last follow-up, the SW-RFA group maintained a superior tumor-free rate (p = 0.010) and fewer progressions to Barcelona Clinic Liver Cancer stage C (p = 0.011). Major complication rates were comparable in both groups (SW-RFA: 2.3% vs. S-RFA: 4.7%, p = 1.000).

CONCLUSIONS

The switching multi-monopolar ablation technique could be beneficial for patients with medium-sized HCCs given sustained control of larger tumors with better overall survival.

KEY POINTS

• Switching monopolar ablation could provide a sustained local tumor control and better overall survival than single-monopolar ablation for the medium-sized hepatocellular carcinoma. • Compared to single-monopolar ablation, switching monopolar ablation could create a larger homogeneous coagulation volume by using a shorter total ablation time to achieve a higher rate of adequate safety margin for a medium-sized HCC. • Patients with medium-sized HCC can be maintained at a higher rate of tumor-free status and at a lower risk of progression into BCLC stage C in the follow-up period after ablation by switching monopolar than by single-monopolar ablation.

The incidence and predictors of post transarterial chemoembolization variceal bleeding in hepatocellular carcinoma patients

BACKGROUND & AIMS

Transarterial chemoembolization (TACE) is the standard of care for intermediate stage hepatocellular carcinoma (HCC) patients. Variceal bleeding is a life-threatening complication and may alter the initial treatment plan. This study was aimed to elucidate the risk factors for variceal bleeding in HCC patients receiving TACE treatment.

METHODS

From 2005 to 2016, a total of 1233 treatment-naive HCC patients receiving first time TACE treatment in Chang Gung Memorial Hospital, Linkou medical center were recruited. Pre-TACE status including baseline characteristics, prior history of ascites, and parameters for liver function evaluation were analyzed. All the variables were compared between patients with and without variceal bleeding.

RESULTS

Among the 1233 patients, the median age was 63.7 (range 25.8-91.5) years old, and 73.5% were male. Variceal bleeding events were documented in 19 patients (1.5%) within 3 months post TACE treatment. Patients with younger age, cirrhosis, pre-treatment ascites and advanced fibrosis status (higher MELD score, CTP score, ALBI grade, FIB-4 and APRI score) were more likely to encounter post-treatment variceal bleeding. Multivariate Cox regression analysis revealed existence of ascites (adjusted HR: 4.859 (1.947-12.124), p = 0.001), and higher FIB-4 score (adjusted HR: 4.481 (1.796-11.179), p = 0.001) were the independent predictive factors for variceal bleeding. Patients with post-TACE variceal bleeding are more likely to encounter tumor progression (42.1% vs. 20.3%, p = 0.039) and mortality owing to GI bleeding (15.8% vs. 3%, p = 0.032).

CONCLUSION

The incidence of post-TACE variceal bleeding was 1.5%. Patients with post-TACE variceal bleeding have poorer TACE treatment response. The pre-treatment ascites and FIB-4 score are the independent predictors for post-TACE variceal bleeding.

Integrated genomic analyses in PDX model reveal a cyclin-dependent kinase inhibitor Palbociclib as a novel candidate drug for nasopharyngeal carcinoma

Background

Patient-derived xenograft (PDX) tumor model has become a new approach in identifying druggable tumor mutations, screening and evaluating personalized cancer drugs based on the mutated targets.

Methods

We established five nasopharyngeal carcinoma (NPC) PDXs in mouse model. Subsequently, whole-exome sequencing (WES) and genomic mutation analyses were performed to search for genetic alterations for new drug targets. Potential drugs were applied in two NPC PDX mice model to assess their anti-cancer activities. RNA sequencing and transcriptomic analysis were performed in one NPC PDX mice to correlate with the efficacy of the anti-cancer drugs.

Results

A relative high incident rate of copy number variations (CNVs) of cell cycle-associated genes. Among the five NPC-PDXs, three had cyclin D1 (CCND1) amplification while four had cyclin-dependent kinase inhibitor CDKN2A deletion. Furthermore, CCND1 overexpression was observed in > 90% FFPE clinical metastatic NPC tumors (87/91) and was associated with poor outcomes. CNV analysis disclosed that plasma CCND1/CDKN2A ratio is correlated with EBV DNA load in NPC patients’ plasma and could serve as a screening test to select potential CDK4/6 inhibitor treatment candidates. Based on our NPC PDX model and RNA sequencing, Palbociclib, a cyclin-dependent kinase inhibitor, proved to have anti-tumor effects by inducing G1 arrest. One NPC patient with liver metastatic was treated with Palbociclib, had stable disease response and a drop in Epstein Barr virus (EBV) EBV titer.

Conclusions

Our integrated information of sequencing-based genomic studies and tumor transcriptomes with drug treatment in NPC-PDX models provided guidelines for personalized precision treatments and revealed a cyclin-dependent kinase inhibitor Palbociclib as a novel candidate drug for NPC.

Electronic supplementary material

The online version of this article (10.1186/s13046-018-0873-5) contains supplementary material, which is available to authorized users.

Investigations of organ and effective doses of abdominal cone-beam computed tomography during transarterial chemoembolization using Monte Carlo simulation

BACKGROUND

To investigate the organ dose, effective dose (ED), conversion factor, and the C-arm rotation angle effects on dose variations of abdominal C-arm cone-beam computed tomography (CBCT) during transarterial chemoembolization (TACE).

METHODS

The organ doses and EDs for abdominal C-arm CBCT were retrospectively calculated according to a Monte Carlo technique for 80 patients. Dose variations from projections, ED to dose-area product (DAP) ratios, and effects of body mass index (BMI) on the ED and ED to DAP ratios were also analyzed.

RESULTS

The kidney received the highest dose (14.6 ± 1.2 mSv). Organ dose deviations among C-arm rotation angles was highest for stomach (CV = 0.71). The mean ED of the the CBCT run during TACE was 3.5 ± 0.5 mSv, and decreased with increased BMI (R² = 0.45, p < 0.001). The mean ED to DAP ratio was 0.27 ± 0.04 mSv·Gy^- 1·cm^- 2 and tended to decrease with increased BMI (R² = 0.55, p < 0.001). The mean ED to DAP ratios were 0.29 ± 0.02, 0.26 ± 0.02, and 0.23 ± 0.03 mSv·Gy^- 1·cm^- 2 for patients with BMI < 25 kg/m², 25-30 kg/m², and ≥30 kg/m², respectively.

CONCLUSIONS

Suitable conversion factors for C-arm CBCT facilitate the use of DAPs for estimating the ED. The patient dose can be varied by adjusting the CBCT rotation angle setting, and dose reduction strategies can be further manipulated.

Correlation between overall survival and differential plasma and tissue tumor marker expression in nasopharyngeal carcinoma patients with different sites of organ metastasis

Differential overall survival of nasopharyngeal carcinoma (NPC) with different organ site metastases has been documented. Here, we attempted to determine the underlying mechanisms by assessing plasma and tumor tissue markers in relation to patient survival. Pretreatment plasma Epstein-Barr virus (EBV) DNA concentrations, cytokines and tissue macrophages, proliferation and apoptosis markers were determined in 178 patients with metastatic NPC. The median overall survival (OS) was 19 months. Patients with single organ metastases had better outcomes than those with multiple organ metastases (median OS: 26 months vs. 16 months), with statistical significance. Among the single organ involvement cases, patients with lung metastasis only showed longer survival than those with bone or liver involvement (median OS: 50 months vs. 21 months vs. 18 months; P < 0.001). Pretreatment plasma EBV DNA concentrations were lower in patients with lung metastasis than bone or liver metastasis among single organ site groups. Plasma interferon-γ-inducible protein-10 (IP-10) and monocyte chemotactic protein-1 (MCP-1) expression levels were correlated with differential single organ site metastasis OS and EBV DNA load. Liver metastatic tissue had higher density of infiltrating macrophages and proliferative index than the lung metastatic group. Low pretreatment plasma EBV DNA load, expression of cytokines, such as IP-10 and MCP-1, tissue macrophage infiltration, and proliferative index may contribute to the differences in overall survival.

Application of a patient-derived xenograft model in cytolytic viral activation therapy for nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC) is an Epstein Barr virus (EBV)-related malignancy in which the tumor microenvironment plays a pivotal role in tumor progression. Here, we developed two patient-derived xenograft (PDX) mouse lines from engrafted NPC metastatic tumors. Positive staining for EBV-encoded small RNAs confirmed that these tumors harbored EBV, and gene expression profile analyses further showed that the PDX was highly similar to the primary parent tumor. In vivo drug screening using the PDX system demonstrated that gemcitabine had the best antitumor effect among the tested drugs. The donor of this PDX also showed excellent responsiveness to gemcitabine treatment. The combination of gemcitabine and valproic acid exerted synergistic antitumor effects. Further addition of ganciclovir to this two-drug combination regimen enhanced cytolytic viral activation, yielding the best antitumor response among tested regimens. Treatment with this three-drug combination regimen decreased plasma EBV-DNA load, tumor viral concentration, and the number of viable tumor cells to a greater extent than the two-drug gemcitabine and valproic acid combination. These results highlight the value of PDX models in the development of EBV-targeted strategies to treat NPC.

Abstract 626: Application of patient-derived xenograft model in nasopharyngeal carcinoma research

Nasopharyngeal carcinoma (NPC) was an Epstein Barr virus (EBV)-related malignancy and tumor microenvironment had a pivotal role in tumor progression. Paucity of good NPC animal models hindered the research in this field. Recently, patient-derived xenograft (PDX) had been shown to be a good preclinical model for drug screening and cancer related research. We had developed two PDX mice lines from engrafting NPC metastatic tumors. Positive EBV-encoded small RNAs staining confirmed these tumors harboring EBV. Further gene expression profile analysis showed higher similarity of PDX to primary parent tumor than NPC cell line xenograft. In vivo drug screening in the PDX system demonstrated gemcitabine had the best antitumor effect among the tested drugs. In this PDX corresponding patient also showed excellent response to gemcitabine treatment. Combination of gemcitabine and valproic acid had synergistic antitumor effect. Further adding ganciclovir in this two combined regimen enhancing cytolytic viral activation had the best antitumor response among the tested regimens. This three combined regimen treated group had lower plasma EBV-DNA load and tumor viral concentration and less viable tumor cells than gemcitabine + valproic acid group. These promising results would open a new era for EBV-targeting therapy in NPC treatment.

Citation Format: Cheng-Lung Hsu, Yung-Chia Kuo, Yenlin Huang, Yin-Cheng Huang, Kar-Wai Lui, Kai-Ping Chang, Tung-Liang Lin, Hsien-Chi Fan, An-Chi Lin, Chia-Hsun Hsieh, Li-Yu Lee, Hung-Ming Wang, Hsin-Pai Li, Angel Chao, Yu-Sun Chang. Application of patient-derived xenograft model in nasopharyngeal carcinoma research. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 626.

Impact of spontaneous tumor rupture on prognosis of patients with T4 hepatocellular carcinoma

Background and objectives

Compare the outcomes of three groups of patients with T4 hepatocellular carcinoma (HCC): tumor rupture with shock (RS group), tumor rupture without shock (R group), and no tumor rupture (NR group).

Materials and Methods

We retrospectively reviewed 221 patients with T4 HCC from 2010 to 2012. The clinical background and prognosis were analyzed.

Results

Overall in‐hospital mortality rate was 18.1%; overall median survival time was 4 months. The NR group were more likely to have multiple and infiltrative tumors (P < 0.001). Relative to the NR group, the R + RS group had better survival rates at 6 months (49.2% vs. 32.2%), 1 year (35.3% vs. 21.0%), 3 years (22.5% vs. 11.0%), and 5 years (17.7% vs. 5.5%) (P = 0.010). Patients in the RS group had a higher in‐hospital mortality rate, but significantly better long‐term survival than the NR and R group (P < 0.001). Multivariate analysis indicated that Child‐Pugh class B or C, presence of portal venous thrombosis, and absence of shock were significantly associated with poor survival.

Conclusion

Patients with tumor rupture and shock had worse in‐hospital survival. However, patients without decompensated liver cirrhosis and portal venous thrombosis, and eligible for curative treatment had favorable long‐term outcome. J. Surg. Oncol. 2016;113:789–795. © 2016 The Authors. Journal of Surgical Oncology Published by Wiley Periodicals, Inc.

Triphasic dynamic CT findings of 63 hepatic focal nodular hyperplasia in 46 patients: correlation with size and pathological findings

BACKGROUND

To correlate the dynamic computed tomography (CT) of hepatic focal nodular hyperplasia (FNH) with its size and pathology.

METHODS

The clinical data, pathological and dynamic CT findings of 36 FNHs in 24 males and 27 lesions in 22 females were reviewed. The pathological and CT findings of the 32 small FNHs (diameter < 3 cm) and 31 large FNHs (diameter >or= 3 cm) were compared and analyzed.

RESULTS

All FNHs were hypervascular at arterial phase except for central scarring. The mean diameter of FNHs with hypoattenuating, isoattenuating, hyperattenuating on delayed scans were 5.05 cm, 3.06 cm, and 2.70 cm, respectively (p = 0.026). As compared with small FNHs, large ones were significantly more likely to reveal central scarring (p = 0.005), vascular displacement (p < 0.001), and abnormal vessels around lesions (p < 0001). Coexistent bile ductile proliferation and bridging septa were more commonly observed in small FNHs (p = 0.028 for both). FNHs without aberrant vessels tended to feature hyperattenuating during the portal venous phase (p = 0.041).

CONCLUSIONS

FNHs with different tumor sizes may manifest various dynamic CT findings that are more or less related to the different pathological findings.

T-Fastener Gastropexy and Percutaneous Gastrostomy Under CT-Fluoroscopic Guidance in a Patient with Partial Gastrectomy

The real-time images of computed tomography (CT)-fluoroscopy provide an excellent means of guidance for percutaneous interventions. We describe the performance of T-fastener gastropexy and percutaneous gastrostomy under CT-fluoroscopic guidance in a 59-year-old woman who had received total pharyngolaryngectomy for hypopharyngeal cancer and partial gastrectomy with Billroth II anastomosis for bleeding gastric ulcer 10 years before this operation. The previous gastric operation altered the gastrointestinal anatomy and made conventional fluoroscopic-guided percutaneous gastrostomy extremely difficult and risky. The T-fastener gastropexy and percutaneous gastrostomy were accomplished smoothly in a single session using CT-fluoroscopic guidance. This modified method of percutaneous gastrostomy may be useful in patients with anatomic distortion due to previous gastric surgery.

Gallbladder polyp as a manifestation of hemobilia caused by arterial-portal fistula after percutaneous liver biopsy: A case report

Outpatient percutaneous liver biopsy is a common practice in the differential diagnosis and treatment of chronic liver disease. The major complication and mortality rate were about 2-4% and 0.01-0.33% respectively. Arterio-portal fistula as a complication of percutaneous liver biopsy was infrequently seen and normally asymptomatic. Hemobilia, which accounted for about 3% of overall major percutaneous liver biopsy complications, resulted rarely from arterio-portal fistula We report a hemobilia case of 68 years old woman who was admitted for abdominal pain after liver biopsy. The initial ultrasonography revealed a gallbladder polypoid tumor and common bile duct (CBD) dilatation. Blood clot was extracted as endoscopic retrograde cholangiopancreatography (ERCP) showed hemobilia. The patient was shortly readmitted because of recurrence of symptoms. A celiac angiography showed an intrahepatic arterio-portal fistula. After superselective embolization of the feeding artery, the patient was discharged uneventfully. Most cases of hemobilia caused by percutaneous liver biopsy resolved spontaneously. Selective angiography embolization or surgical intervention is reserved for patients who failed to respond to conservative treatment.

Ultrasonography-guided core-needle biopsy of parotid gland masses

BACKGROUND AND PURPOSE

An accurate diagnosis of a parotid gland mass is essential for adequate management. We determined the clinical efficacy of USCNB in diagnosing parotid gland masses by using cutting needles of different bores.

METHODS

We reviewed records for 40 benign and 13 malignant parotid lesions. USCNB was performed by using 14-20-gauge needles (mean, 16.6 gauge) with one to five (mean, 2.43) passes and a 15-mm throw or specimen notch. Final diagnoses were established on the basis of surgicopathologic results in 31 cases, and on the basis of histopathologic analysis of biopsy specimens, clinical data, and/or imaging studies in 22, with a follow-up of 12.2-77.5 months (mean, 33.6 months).

RESULTS

Compared with surgicopathology, USCNB had a sensitivity of 83%, a specificity of 100%, and an accuracy of 97% in providing specific tissue diagnoses and in differentiating malignant from benign masses. Its positive and negative predictive values were 100% and 96%, respectively, in diagnosing malignancy. One patient (2%) had a local hematoma without sequela after surgical removal of a Warthin tumor. Core biopsy results were completely concordant with surgical findings in 30 (97%) of 31 cases.

CONCLUSION

USCNB is a safe and efficient diagnostic procedure with an accuracy of 97% in the pathologic diagnosis of parotid masses. It can be performed in an outpatient clinic and enables specific tissue diagnosis to obviate intraoperative frozen biopsy and unnecessary surgery. An 18-gauge needle is sufficient for accurate and specific tissue diagnosis of parotid masses.

Risk Factors of Pneumothorax and Bleeding

BACKGROUND

The results of studies identifying the risk factors for pneumothorax and bleeding in CT-guided coaxial lung needle biopsies were inconsistent and some were even contradictory. All reported series were small with patient populations averaging about 200.

STUDY OBJECTIVES

To determine the risk factors for pneumothorax and bleeding after CT-guided coaxial cutting needle biopsy of lung lesions.

DESIGN

Retrospective analysis.

METHODS

We reviewed 660 biopsy procedures. The risk factors for pneumothorax and bleeding were determined by multivariate analysis of variables related to patient demographics, lung lesions, biopsy procedures, and the individual radiologist.

RESULTS

The main complications were pneumothorax (23%; 155 of 660 procedures), chest tube insertion (1%; 9 of 660 procedures), and hemoptysis (4%; 26 of 660 procedures), with no patient mortality. The highest pneumothorax rate correlated with a lesion size of </= 2 cm, a lesion depth of 0.1 to 2 cm, and less experienced radiologists. The highest bleeding risk correlated with a lesion size </= 2 cm, a lesion depth of >/= 2.1 cm, and the absence of pleural effusion.

CONCLUSIONS

The risk factors for highest pneumothorax rate are lesion size </= 2 cm, a subpleural lesion depth of 0.1 to 2.0 cm, and a less experienced radiologist. The risk factors for highest bleeding rate are lesion size </= 2 cm, lesion depth >/= 2.1 cm, and lung lesions not associated with a pleural effusion.

Radiofrequency ablation: an alternative treatment method of renal cell carcinoma

Renal Cell Carcinoma (RCC) is a common renal parenchymal malignancy. Although complete or partial nephrectomy is still the gold standard of management, a lot of minimally invasive techniques are currently emerging into the field of treatment. Recently, image-guided radiofrequency (RF) ablation has received increasing attention and been proposed as an alternation to more invasive procedures such as partial or radical nephrectomy. For the RCC patients who are not amenable to surgery or have a single kidney, RF ablation is another feasible option of management. We present a 71-year-old patient who had right nephrectomy for RCC 10 years prior to admission, and hypertension and arrhythmia under regular treatment. He was noted to have two masses in the left kidney and right adrenal gland, respectively, on follow-up computed tomography images. Percutaneous biopsies of the left renal and right adrenal masses were proven to be renal cell carcinoma. After a right adrenalectomy was performed, this patient underwent two treatment sessions of percutaneous RF ablation to avoid a nephrectomy which would lead her on dialysis. Successful treatment was impressed after 1 year of follow-up. We report this case to emphasize the potential role of percutaneous RF ablation on the treatment of RCC.

Role of CT-guided core needle biopsy in the diagnosis of a gossypiboma: case report

A 66-year-old woman with previous hysterectomy had dysuria and vaginal spotting for 1 month. Computed tomography showed a heterogeneous presacral mass with eccentric calcification. Biopsies of the bladder and vagina and transrectal biopsy of the pelvic mass yielded only inflammation. T2-weighted magnetic resonance images revealed a heterogeneous mass with wavy hypointensities. Computed tomographically guided biopsy targeting at the calcified area disclosed thread-like materials, thus confirming the diagnosis of gossypiboma.

Fluoroscopically guided percutaneous gastrostomy with modified gastropexy and a large-bore balloon-retained catheter in patients with head and neck tumors

PURPOSE

To report on fluoroscopically guided percutaneous gastrostomy (FPG) using a modified gastropexy technique with the insertion of a large-bore balloon-retained gastrostomy catheter in patients with head and neck tumors.

MATERIAL AND METHODS

Thirty-four patients with head and neck tumors underwent a modified gastropexy with two T-fasteners followed by the insertion of a 14-F ballooon-retained catheter through a peel-away introducer. The success rate and the complications of the procedures were evaluated at 14 days, 30 days, and 60 days. The complications were classified as: major complications that necessitated intensive and/or surgical treatment; minor complications that could be treated conservatively; and tube-related complications manageable by tube exchange.

RESULTS

FPG was technically successful in all cases. There were no major complications, two minor complications where superficial stoma infection was controlled by antibiotics, three minor tube-related complications, all three easily managed by catheter replacement via the original tract.

CONCLUSION

FPG with insertion of a large-bore balloon-retained catheter using a modified gastropexy technique is a safe and effective method that creates a feeding access for patients with head and neck tumors and esophageal obstruction. Minor complications can be managed conservatively. FPG may be a good alternative to surgical or percutaneous endoscopic gastrostomy.

Value of Dual-Phase 2-Fluoro-2-Deoxy-d-Glucose Positron Emission Tomography in Cervical Cancer

Purpose: The role of positron emission tomography (PET) with fluorine-18–labeled fluoro-2-deoxy-d-glucose (FDG) in cervical cancer has not yet been well defined. We conducted a prospective study to investigate its efficacy in comparison with magnetic resonance imaging and/or computed tomography (MRI-CT).

Materials and Methods: Patients with untreated locally advanced (35%) or recurrent (65%) cervical cancer were enrolled onto this study. In the first part of this study, 41 patients had a conventional FDG-PET (40 minutes after injection), and in the second part, 94 patients received dual-phase PET (at both 40 minutes and 3 hours after injection). The overall results of PET scans were compared with MRI-CT, and the two protocols of PET were also compared with each other. Lesion status was determined by pathology results or clinical follow-up. The receiver operating characteristic curve method with area under the curve (AUC) calculation was used to evaluate the discriminative power.

Results: Overall (N = 135), FDG-PET was significantly superior to MRI-CT in identifying metastatic lesions (AUC, 0.971 v 0.879; P = .039), although the diagnostic accuracy was similar for local tumors. Dual-phase PET was also significantly better than the 40-minute PET (n = 94). The latter accurately recognized 70% of metastatic lesions and the former detected 90% (AUC, 0.943 v 0.951; P = .007). Dual-phase FDG-PET changed treatment of 29 patients (31%; upstaging 27% and downstaging 4%).

Conclusion: This study shows that dual-phase FDG-PET is superior to conventional FDG-PET or MRI-CT in the evaluation of metastatic lesions in locally advanced or recurrent cervical cancer.

Factors affecting diagnostic accuracy of CT-guided coaxial cutting needle lung biopsy: retrospective analysis of 631 procedures

PURPOSE

To analyze variables affecting diagnostic accuracy of computed tomography (CT)-guided percutaneous coaxial cutting needle biopsy of lung lesions.

MATERIALS AND METHODS

A retrospective analysis of factors affecting diagnostic accuracy of CT-guided percutaneous coaxial cutting needle lung biopsy was performed in 631 consecutive procedures with confirmed final diagnoses. Benign and malignant needle biopsy results were cross-examined with correct and incorrect final outcomes to determine diagnostic accuracy. Factors affecting diagnostic accuracy were determined by multivariate logistic regression analysis of variables thought to affect diagnostic accuracy. A P value less than 0.05 was interpreted as statistically significant.

RESULTS

The overall diagnostic accuracy of CT-guided percutaneous coaxial cutting needle biopsy of lung lesions was 95% (95% CI: 92.7%-96.2%). Sensitivity was 93%, specificity 98%, negative predictive value 6%, positive predictive value 99%, false-positive rate 0.7%, and false-negative rate 15%. The factors affecting diagnostic accuracy were final diagnoses (benign, 86%; malignant, 99%; chi(2) test, P < 0.001) and lesion size (lesions <1.5 cm, 84%; lesions 1.5-5.0 cm, 96%; lesions >5 cm, 93%; chi(2) test, P = 0.06).

CONCLUSION

Benign lung lesions, lung lesions smaller than 1.5 cm (which pose technical difficulty), and lung lesions larger than 5 cm (which are associated with a higher necrosis rate) affect diagnostic accuracy of CT-guided percutaneous coaxial cutting needle biopsy of lung lesions.

Sonographic evaluation of mammographically detected microcalcifications without a mass prior to stereotactic core needle biopsy

PURPOSE

The purpose of this prospective study was to evaluate the clinical usefulness of sonographically re-evaluating areas of microcalcification found mammographically before undertaking stereotactic core needle biopsy (SCNB).

METHODS

Patients with nonpalpable breast lesions appearing as microcalcifications on mammograms and who had been referred to us for SCNB were re-evaluated sonographically before the procedure. None of the breast lesions had been associated with a density on the mammograms, and the initial sonographic evaluations had been negative. Using the mammograms for correlation, we meticulously re-evaluated the areas of microcalcifications sonographically using a high-frequency linear-array transducer. The sonographic and histopathologic results were then reviewed and correlated. The sonographic findings and visibility of the mammographically detected microcalcifications were analyzed by the 2-tailed Fisher's exact test and the chi-square test.

RESULTS

Sixty-six patients, who had 68 cases of microcalcifications, were enrolled. Thirteen of the 66 patients underwent surgery, and 9 of the 13 were found to have breast carcinoma. In the sonographic re-evaluation before SCNB in these 9 patients, an associated soft tissue mass was demonstrated in 5 patients but not in the other 4. Sonographic re-evaluation also revealed abnormalities in 24 of 68 cases (35.3%), in contrast to the negative findings on the initial sonography. Using the chi-square test to identify a trend, we found that the percentage of cases that were sonographically visible was highest for clustered benign microcalcifications and lowest for segmental benign microcalcifications (p < 0.0001).

CONCLUSIONS

In breast lesions that appear as microcalcifications without an associated mass on mammograms, pre-SCNB sonographic re-evaluation with a high-frequency transducer can depict microcalcifications, particularly the clustered ones, and can detect small associated masses. Although the absence of a sonographically detectable mass in areas of mammographically detected microcalcifications does not guarantee the absence of cancer, the presence of an associated mass on sonography should warrant close follow-up in the case of negative results to avoid a delay in the diagnosis of breast carcinoma.

Splenic abscess: diagnosis and management

BACKGROUND/AIMS

To evaluate the usefulness of a combination of computed tomography and sonography for splenic abscess diagnosis and management determination.

METHODOLOGY

From January 1986 to June 1999, 30 patients of pyogenic splenic abscess were collected in our hospital. Computed tomograms of the spleen were performed on all of the patients, and abdominal sonographies were performed on 26 of them. The imaging findings of all the patients were reviewed with respect to the clinical presentations, predisposing factors, infective organisms, method of treatment and clinical outcome.

RESULTS

The clinical triad of splenic abscess was the main presentation of the 30 patients; it included fever (92%), left upper abdominal pain (77%) and leukocytosis (66%). Infective bacteria were identified in 19 patients, and the most offending bacteria were aerobes (82.6%). The radiological findings included single abscess were found in 16 patients and multiple abscesses were noted in 14 patients. The computed tomography and sonography findings included abnormal gas content (6 cases), progressive enlargement of lesion (6 cases), subcapsular extension of lesion (6 cases), extracapsular fluid collection (8 cases) and cystic lesion (7 cases). 59% of the cases had at least one of the above imaging findings. With the combination of the clinical triad and the imaging findings, the diagnostic rate rose up to 86.7%.

CONCLUSIONS

Although splenic abscess is rare, it has a high mortality rate if there is delay in diagnosis and treatment. With the combination of computed tomography, sonography and clinical features, early diagnosis and treatment can be made. Percutaneous drainage for single abscess and splenectomy for multiple abscesses are the safe and effective treatment choice. The computed tomography and sonography appearance of splenic abscess is a valuable predictor of outcome of splenic abscess drainage. Medical treatment alone was definitely insufficient.

Risk factors for pneumothorax and bleeding after CT-guided percutaneous coaxial cutting needle biopsy of lung lesions

PURPOSE

To evaluate risk factors for pneumothorax and bleeding after computed tomography (CT)-guided percutaneous coaxial cutting needle biopsy of lung lesions.

MATERIALS AND METHODS

This study involved 117 consecutive patients with 117 intrapulmonary lesions. Statistical analysis of factors related to patient characteristics, lung lesions, and biopsy technique was performed to determine possible contribution to the occurrence of pneumothorax and bleeding. Interactions between related factors were considered to prevent colinearity.

RESULTS

Pneumothorax occurred in 12% (14 of 117) of patients. Needle aspiration of two moderate asymptomatic pneumothoraces were performed; there was no chest tube insertion. Lesion depth (P =.0097), measured from the pleural puncture site to the edge of the intrapulmonary lesion along the needle path, was the single significant predictor of pneumothorax. The highest risk of pneumothorax occurred in subpleural lesions 2 cm or shorter in depth (this represented 33% of lung lesions but caused 71% of all pneumothoraces; OR = 7.1; 95% CI, 1.3-50.8). Bleeding presented as lung parenchyma hemorrhage and hemoptysis in 30 patients (26%). Hemoptysis occurred in four patients (3%). Univariate analysis identified lesion depth (P <.0001), lesion size (P <.015), and pathology type (P =.007) as risk factors for bleeding. Multivariate logistic regression analysis identified lesion depth as the most important risk factor, with the highest bleeding risk for lesions more than 2 cm deep (14% of lesions caused 46% of all bleeding; OR = 17.3; 95% CI, 3.3-121.4).

CONCLUSIONS

In CT-guided coaxial cutting needle biopsy, lesion depth is the single predictor for risk of pneumothorax, which occurs at the highest rate in subpleural lesions. Increased risk of bleeding occurs in lesions deeper than 2 cm.

Air enema for diagnosis and reduction of intussusception in children: clinical experience and fluoroscopy time correlation

PURPOSE

The objective of this study was to correlate the fluoroscopy time with radiologic outcome in the pneumoreduction of intussusception in children.

METHODS

From September 1995 to December 1997, a prospective analysis of 181 cases of pediatric intussusception with pneumoreduction without sedation was done. A receiver operating characteristic curve of fluoroscopy time was drawn for correlation with radiologic outcome.

RESULTS

The overall success and failure rates of pneumoreduction were 84% and 16%, respectively. Three patients (1.6%) experienced colon perforation. The mean fluoroscopy time was 2.8 +/- 1.7 minutes in successful procedure and 4.9 +/- 2.8 minutes in failed procedures (P < 0.001). Analysis of the receiver operating characteristic curve of fluoroscopy time indicates that 4 minutes fluoroscopy time was a good critical point in differentiating successful and failed cases. In those 18 patients who had successful reduction with fluoroscopy times of more than 4 minutes, 4 patients had clinical symptoms for more than 1 day and 14 patients less than 1 day. One of those 4 patients required operation 1 day later because of peritonitis caused by necrosis of terminal ileum. Two patients had high fever in the next 2 days and recovered after antibiotic treatment.

CONCLUSIONS

Pneumoreduction is a good method in treatment of intussusception with high successful rate. Four minutes is the critical point of procedure. Reduction with greater than 4 minutes in those patients having illness more than 1 day might not benefit and have more complications.

Ultrasound guided puncture of the brachial artery for haemodialysis fistula angiography

BACKGROUND

Arterio-venous (a-v) fistulae of haemodialysis patients frequently require function assessment by angiography. The purpose of the present study was to determine the efficacy and safety of ultrasound-guided transbrachial catheterization when a-v fistulae were evaluated.

METHODS

Between July 1996 and December 1997, 208 dialysis patients, whose a-v fistulae (arterial inflow < 50 ml/min or venous pressure > 150 mm Hg in three consecutive HD sessions) were at the wrist or elbow, underwent transbrachial angiography using an ultrasound-guided 20-gauge IA needle to evaluate fistula function. Procedure-related symptoms or complications were noted in 28 patients and these were analysed.

RESULTS

No apparent cases of vessel spasm or thrombosis were noted. Reported symptoms in 28 patients (13.5%) included local arm pain (3.3%), transient paresthesia (0.9%), mild ecchymosis (10.6%) and haematoma (0.9%). All complications were minor and none required surgical intervention.

CONCLUSION

Ultrasound-guided puncture of the brachial artery is a safe, reliable and effective procedure in skilled hands and should be the preferred means of catheterization whenever haemodialysis angiography is performed.

Ultrasonographic findings and differentiation of benign and malignant focal splenic lesions

The purpose of this study was to analyse the sonographic findings of focal splenic lesions with an attempt to differentiate benign lesions from malignancies. The sonographic findings of 53 cases of verified focal splenic lesions, excluding post-traumatic haematomas and phleboliths, were retrospectively analysed. Of the 53 cases, 30 cases (57%) were benign and 23 cases (43%) were malignant. The malignancies included lymphoma (n=13), metastases (n=10); while the benign lesions included cysts (n=17), infarcts (n=3), and abscesses (n=5), and one case each of haemangioma, hamartoma, spontaneous rupture, tuberculosis, and lymphangioma. Significant differences were noted between the benign and malignant groups with respect to the presence of solitary lesions (p<0.0001), anechoic mass (p<0. 0001), lesions with highly echogenic foci due to gas or calcification (p = 0.0303), hyperechoic/mixed echoic lesions (p<0. 0001), presence of extrasplenic abdominal masses (p<0.0001), and nodules with the target sign (p<0.0001). Solitary lesions, anechoic mass, and lesions with highly echogenic foci due to gas or calcification each had a positive predictive value of 85%, 100%, and 100%, respectively, for the lesions to be benign. The multifocal/diffuse lesions, presence of extrasplenic abdominal masses, hyperechoic/mixed echoic lesions, and nodules with the target sign each had a positive predictive value of 70%, 100%, 70%, and 100%, respectively, for the lesions to be malignant. In summary, focal lesions with anechoic pattern or echogenic foci due to gas or calcification are suggestive signs of benign process. The sonographic observations of multifocal or diffuse solid lesions, especially those associated with target sign or extrasplenic abdominal masses are suggestive of malignancy.

Sonographically guided core-needle biopsy in the diagnosis of superficial lymphadenopathy

PURPOSE

This study was designed to evaluate the efficacy of ultrasound-guided percutaneous core-needle biopsy for establishing histopathologic diagnoses of palpable enlarged lymph nodes.

METHODS

Thirty patients without a history of malignancy or recent infection underwent ultrasound-guided core-needle lymph node biopsies. Only patients with enlarged lymph nodes ranging from 1.5 to 3.5 cm in greatest diameter that had been present for more than 2 months were included in this study. Two cores from each lymph node were obtained by a freehand core-needle biopsy technique using a 7-MHz ultrasound transducer and an automatic spring-loaded biopsy gun with an 18-gauge cutting needle.

RESULTS

The histologic diagnoses were conclusive in 24 cases (80%) and inconclusive in 6 cases (20%). In the 24 conclusive cases, the lymph node enlargement was due to benign causes in 12 cases and malignancy in 12 cases. All specimens in the conclusive cases were sufficient for histologic diagnosis, but there was insufficient material for a diagnosis in 3 of the inconclusive cases. No complications were seen in this series.

CONCLUSIONS

Ultrasound-guided core-needle biopsy of enlarged lymph nodes is a safe, minimally invasive alternative to surgical biopsy, enabling a histologic diagnosis for treatment planning in most cases.

Antral web--a rare cause of vomiting in children

Antral web is a rare cause of gastric-outlet obstruction. We report a case of gastric antral web with intermittent vomiting in a 10-year-old girl who received medical treatment for 6 months. The literature on this anomaly is reviewed with respect to differential diagnosis on the basis of upper gastrointestinal radiographic series, gastroscopy, and treatment planning.

Hepatic calcification by sequelae of chronic schistosomiasis japonica: report of four cases

Due to the elimination of intermediate hosts and the improvement of clinical care, most parasitic infections have been effectively controlled in developing countries. Recently, the increase of the worldwide tourism, especially to Mainland China, and the migration of overseas workers from endemic countries have led to more parasitic infections that should not be overlooked by physicians. Assessment of diffuse liver disease with physical examination and laboratory findings is notoriously inaccurate. Thus, physicians use liver biopsy for accurate diagnoses. We present 4 patients with hepatic schistosomiasis japonica which were diagnosed using imaging before liver biopsy. Hepatic schistosomiais japonica has a tendency to cause dystrophic calcification and fibrosis in the liver. According to the results, a combination of ultrasonography and computed tomography (CT), used to recognize characteristic calcification patterns, seem useful to physicians for accurate diagnoses. Thus, unnecessary biopsy procedures can be avoided.

Intractable oesophageal variceal bleeding caused by splenic arteriovenous fistula: treatment by transcatheter arterial embolization

We describe a rare case of splenic arteriovenous fistula and venous aneurysm which developed after splenectomy in a 40-year-old woman who presented with epigastralgia, watery diarrhoea, repeated haematemesis and melaena caused by hyperkinetic status of the portal system and bleeding of oesophageal varices. It was diagnosed by computed tomography and angiography, and obliterated with giant Gianturco steel coils.

A rare abdominal cystic mass with unusual presentation

Images

Three-dimensional magnetic resonance cholangiopancreatography for evaluation of obstructive jaundice

The purpose of this study was to assess the diagnostic value of magnetic resonance cholangiopancreatography (MRCP) in studying the anatomy, sites, and causes of obstructive jaundice. From September 1994 to May 1996 three-dimensional MRCP was performed on 31 patients with abdominal pain and obstructive jaundice with a fast spin-echo T2-weighted pulse sequence. The images were reconstructed using maximal intensity projection, AVERAGE and SURFACE algorithm processing techniques at a graphics workstation. All the reconstructed images were compared with those obtained using conventional cholangiographic techniques, such as endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography and drainage, and intraoperative cholangiography. The patients' diagnoses included choledochal cyst (13), cholangiocarcinoma (five), choledocholithiasis (four), pancreatic head carcinoma (three), rhabdomyosarcoma (one), papillary Vater carcinoma (one), recurrent gastric carcinoma (one), ascaris (one), and biliary atresia (two). Extrahepatic biliary dilatation was present in all 13 patients with choledochal cyst; the pancreatic ducts and their entrance level to the common bile duct were observed in eight of these patients. The level of obstruction in patients with cholangiocarcinoma was well documented but the biliary tract of one patient with biliary atresia was not identified by MRCP. In one patient with biliary rhabdomyosarcoma, MRCP clearly delineated the extrabiliary extension of the tumor. In a patient with ascaris in the common bile duct an increase in signal intensity inside the digestive tract of the worm denoted fluid in its gut. Lithiasis was shown in all of the four patients with choledocholithiasis. Thus, MRCP is a useful tool in the assessment of biliary tract obstruction and its causes, and is a valuable addition to ultrasonography.

MRI of multiple biliary hamartomas

Multiple biliary hamartomas (MBH) are uncommon benign malformations of the bile ducts. A case of MBH simulating liver metastases is reported, the diagnosis having been ascertained by US-guided biopsy. US and CT showed multiple hepatic nodules scattering in both lobes of the liver. Angiography showed small hypovascular lesions as well as hypervascular nodules. Only two cases with MRI studies have previously been reported. In this case, the finding was of hepatic cysts containing intermediate signal mural nodules. Demonstrating hepatic cysts with mural nodules on imaging will considerably increase the accuracy of diagnosis.

Ambulatory 24-hour esophageal pH monitoring. Technology searching for a clinical application

The development of commercially available ambulatory 24 hour pH monitoring systems has expanded the potential use of this technique. In this article the use of these instruments is reviewed and direct comparisons between different techniques are made. Both the transnasal pH probes and the telemetric capsule have potential advantages and disadvantages for both the physician and the patient. Problems with the interpretation of pH recordings are discussed. A symptom index is developed in an attempt to provide a numerical assessment of the direct association between reflux events and symptoms in each individual patient.