Can expiratory or inspiratory contrast-enhanced computed tomography be more efficient for fast-track cannulation of the right adrenal vein in adrenal venous sampling?

PURPOSE

This study compares the usefulness of expiratory arterial phase (EAP)-contrast-enhanced computed tomography (CT) (CECT) with that of inspiratory arterial phase (IAP)-CECT in adrenal venous sampling (AVS).

METHODS

Sixty-four patients who underwent AVS and CECT at the authors' hospital between April 2013 and June 2019 were included in this study. The patients were classified into the following two groups: EAP (32 patients) and IAP (32 patients) groups. The single arterial phase images were obtained at 40 seconds in the IAP group. The double arterial phase images were obtained at 40 seconds in the early arterial phase and 55 seconds in the late arterial phase in the EAP group. The authors then compared the right adrenal vein (RAV) visualization rate on the CECT, the difference between the CECT images and adrenal venograms in the localization of the RAV orifice, the cannulation time to the RAV, and the volume of contrast agent administered intraoperatively between the two groups.

RESULTS

The rates of the RAV visualization in the EAP group were 84.4% in the early arterial phase, 93.8% in the late arterial phase, and 100% in the combined early and late arterial phases. The rate of the RAV visualization in the IAP group was 96.9%. There was no significant difference between the two groups in terms of the rate of the RAV visualization. However, there was a small difference in the location of the RAV orifice between the CECT images and adrenal venograms in the EAP group as compared with the IAP group (P < 0.001). The median time to the RAV catheterization was significantly shorter in the EAP group (27.5 minutes) than in the IAP group (35.5 minutes; P = 0.035). The rates of the RAV visualization in the EAP group were not significant between the early arterial phase, late arterial phase, and combined early and late arterial phases (P = 0.066). However, the mean volume CT dose index in the combined early and late arterial phases was significantly higher than in the early and late arterial phases (P < 0.001).

CONCLUSION

The EAP-CECT is more useful for increasing the speed of the RAV cannulation due to the small difference in the localization of the RAV orifice compared to IAP-CECT. However, since EAP-CECT has double contrast arterial phases and increased radiation exposure compared to IAP-CECT, only the late arterial phase may be acceptable to reduce radiation exposure.

A ruptured splenic artery aneurysm treated by transcatheter arterial embolization using n-butyl cyanoacrylate-Lipiodol-Iopamidol

N-butyl cyanoacrylate, one of embolic materials, is usually used as a mixture with Lipiodol (N-butyl cyanoacrylate-Lipiodol mixture). N-butyl cyanoacrylate-Lipiodol-Iopamidol was developed by adding a nonionic iodine contrast agent (Iopamiron) to N-butyl cyanoacrylate-Lipiodol mixture. N-butyl cyanoacrylate-Lipiodol-Iopamidol has lower adhesiveness than N-butyl cyanoacrylate-Lipiodol mixture and the ability to form a single large droplet. We report the case of a 63-year-old man with a ruptured splenic artery aneurysm treated by transcatheter arterial embolization using N-butyl cyanoacrylate-Lipiodol-Iopamidol. He was referred to the emergency room because of sudden onset of upper abdominal pain. A diagnosis was established using contrast-enhanced computed tomography and angiography. Emergency transcatheter arterial embolization was performed, and the ruptured splenic artery aneurysm was successfully embolized using a combination of coil framing and N-butyl cyanoacrylate-Lipiodol-Iopamidol packing. This case demonstrates the usefulness of a combination of coil framing and N-butyl cyanoacrylate-Lipiodol-Iopamdol packing for the embolization of aneurysms.

Classification tree analysis to evaluate the most useful magnetic resonance image type in the differentiation between early and progressed hepatocellular carcinoma

AIM

Using classification tree analysis, we evaluated the most useful magnetic resonance (MR) image type in the differentiation between early and progressed hepatocellular carcinoma (eHCC and pHCC).

METHODS

We included pathologically proven 214 HCCs (28 eHCCs and 186 pHCCs) in 144 patients. The signal intensity of HCCs was assessed on in-phase (T1in) and opposed-phase T1-weighted images (T1op), ultrafast T2-weighted images (ufT2WI), fat-saturated T2-weighted images (fsT2WI), diffusion-weighted images (DWI), contrast enhanced T1-weighted images in the arterial phase (AP), portal venous phase (PVP), and the hepatobiliary phase. Fat content and washout were also evaluated. Fisher's exact test was performed to evaluate usefulness for the differentiation. Then, we chose MR images using binary logistic regression analysis and performed classification and regression tree analysis with them. Diagnostic performances of the classification tree were evaluated using a stratified 10-fold cross-validation method.

RESULTS

T1in, ufT2WI, fsT2WI, DWI, AP, PVP, fat content, and washout were all useful for the differentiation (p < 0.05), and AP and T1in were finally chosen for creating classification trees (p < 0.05). AP appeared in the first node in the tree. The area under the curve, sensitivity and specificity for eHCC, and balanced accuracy of the classification tree were 0.83 (95% CI 0.74-0.91), 0.64 (18/28, 95% CI 0.46-0.82), 0.94 (174/186, 95% CI 0.90-0.97), and 0.79 (95% CI 0.70-0.87), respectively.

CONCLUSIONS

AP is the most useful MR image type and T1in the second in the differentiation between eHCC and pHCC.

Audiological Features in 63 Patients With Cochlear Nerve Deficiency

OBJECTIVE

We aimed to investigate the clinical features of cochlear nerve deficiency (CND), and in particular, the long-term course of hearing disability and audiogram shapes.

STUDY DESIGN

Retrospective observational nonrandomized group study.

SETTING

Academic medical center.

PATIENTS/INTERVENTIONS

The subjects were 63 children with congenital hearing loss who visited our hospital between 2009 and 2019 and underwent MRI, based on which they were diagnosed with CND. There were 61 cases of unilateral CND and two cases of bilateral CND.

MAIN OUTCOME MEASURES

Imaging tests by MRI and CT and audiometric assessments by pure-tone audiometry and distortion product otoacoustic emission were performed.

RESULTS

Among the cases of CND diagnosed by assessing the cochlear nerve on MRI, approximately 20% of the bony cochlear nerve canals that could be assessed on CT were normal. Of the 61 cases diagnosed with unilateral CND, 55 cases had cochlear nerve aplasia (90.2%), and six had cochlear nerve hypoplasia (9.8%), with a mean hearing ability of 92.2 and 94.6 dB HL, respectively. Thus, the majority of cases had severe-to-profound hearing loss. The overall audiometric patterns were 78.7% flat, 9.8% cookie-bite, and 9.8% high-frequency. Six of 61 cases (9.8%) had a distortion product otoacoustic emission (DPOAE) response based on the affected side, and none of the cases lost the response during follow-up.

CONCLUSIONS

Herein, we report the largest study on CND and performed CND image and audiometric assessments. Accurately in diagnosing CND requires not only CT but also MRI assessment. Hearing loss is often severe to profound; however, various audiometric patterns have been observed. CND includes a small number of cases that respond to DPOAE, indicating that some CND cases are clinically diagnosed with auditory neuropathy spectrum disorder (ANSD). A sustained DPOAE response might help in differentiating CND from other ANSDs. Children with congenital deafness who have passed the newborn hearing screening by DPOAE should be examined by MRI to rule out CND.

Preoperative Arterial Embolization to Avoid Intraoperative Bleeding during Endoscopic Sinus Surgery for Organized Hematoma of the Maxillary Sinus: A Case Series and Literature Review

Purpose:

This study aimed to evaluate the safety and efficacy of preoperative arterial embolization of organized hematoma of the maxillary sinus.

Material and Methods:

Seven patients who were pathologically diagnosed with an organized hematoma of the maxillary sinus and who underwent endoscopic sinus surgery following preoperative arterial embolization for the same from July 2013 to April 2020 at our hospital were included. A literature review of the PubMed database was performed to identify 13 cases on organized hematomas of the maxillary sinuses. The embolization and nonembolization groups comprised patients who underwent preoperative embolization (n = 10, seven from this study and three from literature) and those who did not undergo preoperative embolization (n = 10, from literature), respectively. Outcomes of embolization including embolization-related complications and postoperative bleeding were assessed, and volumes of intraoperative blood loss and duration of surgery were compared between the groups.

Results:

No preoperative embolization-related complications were observed in our cases. The volume of surgical blood loss in the seven cases varied from 0 to 100 mL with a median of 30 mL, and the duration of surgery ranged from 45 to 166 minutes with a median of 112 minutes. The volume of blood loss was significantly lower for the embolization group than that for the nonembolization group (p = 0.0031). There was no statistically significant difference regarding duration of surgery between the groups (p > 0.10).

Conclusions:

Preoperative embolization of an organized hematoma of the maxillary sinus is a safe and effective method that helps prevent serious intraoperative hemorrhage.

Segmental Hepatic Steatosis Due to Portal Vein Stricture After Pediatric Living Donor Liver Transplantation: A Case Report

BACKGROUND AND OBJECTIVE

Liver transplantation (LT) is the gold-standard treatment for end-stage liver disease; however, late-onset complications such as fatty liver can occur in the absence of metabolic comorbidities. We report a unique case of post-transplant hepatic steatosis developing in only a part of the liver graft.

CASE REPORT

A 1-year-old boy underwent ABO-incompatible living donor liver transplantation (LDLT) with a left lateral liver graft donated from his mother for biliary atresia. The biliary tract was reconstructed by hepaticojejunostomy using the previous Roux-en-Y limb. Liver function tests increased by up to 2-fold of the upper normal limit after the second year. He developed segmental steatosis in a part of the liver graft 2 years after LDLT. Venous blood drained into the area of the liver graft from veins in the Roux-en-Y limb of the jejunum. Pathologic findings from a liver biopsy showed fatty depositions without steatohepatitis, acute rejection, or tumors. Portal vein stricture (PVS) subsequently became apparent, which was complicated by the symptoms of portal hypertension, such as gastrointestinal varices. We treated PVS with 2 sessions of percutaneous transhepatic portal vein angioplasty (PTPA), after which the segmental steatosis disappeared. We hypothesize that PVS caused local hemodynamic anomalies, leading to fatty deposition in a part of the liver graft.

CONCLUSION

We experienced a case of post-LT with segmental steatosis that was successfully treated by portal vein flow modification with PTPA. Steatosis of the graft might indicate a vascular abnormality, and further examinations should be performed after LT.

Compartment model analysis of intravenous contrast-enhanced dynamic computed tomography in hepatic hemodynamics: A validation study using intra-arterial contrast-enhanced computed tomography

AIM

To verify the utility of the 2-in-1-out-compartment model analysis (CMA) of intravenous contrast-enhanced dynamic computed tomography (IV-CT) for evaluating hepatic arterial and portal venous flow using intra-arterial contrast-enhanced CT (IA-CT).

METHODS

We retrospectively evaluated 49 consecutive patients who underwent IV-CT and were radiologically or histologically diagnosed as having hepatic malignant lesion (51 classical hepatocellular carcinomas [HCC], 4 early HCC, 3 cholangiolocellular carcinomas, 1 mixed HCC, 3 cholangiocellular carcinomas). As a gold standard for hepatic arterial and portal blood flows, we defined the normalized enhancement in CT values on CTAP (nCTAP) and CTHA (nCTHA). The hepatic arterial (k_1a ) and portal venous inflow velocity (k_1p ) constants in hepatic lesions and surrounding liver parenchyma were obtained from the CMA of IV-CT with various outflow velocity constant (k₂ ) limits using the nonlinear least square method. The correlation coefficient between the normalized enhancement in IA-CT and CMA of IV-CT was statistically evaluated according to various k₂ limits.

RESULTS

The highest mean correlation coefficient between k_1a and nCTHA (r = 0.65, P < 0.0001) was observed when k₂ ≦0.035. The highest mean correlation coefficient between k_1p and nCTAP (r = 0.69, P < 0.0001) was observed when k₂ ≦0.045. The decrease in correlation coefficient was significant when the upper k₂ limit was lower than 0.03 or higher than 0.07 compared to the best mean correlation coefficient (P < 0.05).

CONCLUSION

Hepatic arterial and portal venous flows can be evaluated quantitatively to some extent with appropriate outflow velocity constant limits using the CMA of IV-CT.

Evaluation of hemodynamic imaging findings of hypervascular hepatocellular carcinoma: comparison between dynamic contrast-enhanced magnetic resonance imaging using radial volumetric imaging breath-hold examination with k-space-weighted image contrast reconstruction and dynamic computed tomography during hepatic arteriography

PURPOSE

To compare the visualization of hemodynamic imaging findings of hypervascular hepatocellular carcinoma (HCC) on dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) using radial volumetric imaging breath-hold examination with k-space-weighted image contrast reconstruction (r-VIBE-KWIC) versus dynamic computed tomography during hepatic arteriography (dyn-CTHA).

MATERIALS AND METHODS

We retrospectively reviewed the databases of preoperative DCE-MRI using r-VIBE-KWIC, dyn-CTHA, and postoperative pathology of resected specimens. Fourteen patients with 14 hypervascular HCCs underwent both DCE-MRI and dyn-CTHA. The imaging findings of the tumor and adjacent liver parenchyma were assessed on both modalities by two readers. The tumor enhancement time was also compared between the two modalities.

RESULTS

On DCE-MRI/dyn-CTHA, early staining, peritumoral low-intensity or low-density bands, corona enhancement, and washout of HCC were observed in 14/14 (100%), 10/12 (83%), 11/14 (78%), and 4/14 (29%) patients, respectively. Pathologically, four HCCs with low-density bands on dyn-CTHA had no fibrous capsules. The median tumor enhancement time on DCE-MRI and dyn-CTHA was 24 (9-24) and 23 (8-35) s, respectively. The correlation coefficient between the two groups was 0.762 (P < 0.002).

CONCLUSIONS

DCE-MRI using r-VIBE-KWIC has diagnostic potential comparable with that of dyn-CTHA in the hemodynamic evaluation of hypervascular HCC except for the washout phenomenon.

Evaluation of splenic perfusion and spleen size using dynamic computed tomography: Usefulness in assessing degree of liver fibrosis

AIM

To enhance the usefulness of splenic perfusion evaluated by means of dynamic computed tomography (CT) and spleen size in assessing the degree of liver fibrosis.

METHODS

We retrospectively studied 133 patients who had undergone dynamic CT before hepatectomy. Fibrosis was histologically established in all. First we calculated splenic perfusion parameters K₁ (inflow rate constant), 1/k₂ (mean transit time; MTT), and K₁ /k₂ (distribution volume; V_d ), using compartment model analysis. Then we compared the stage of fibrosis with splenic perfusion and spleen size (long axis, R), using the Kruskal-Wallis test and multiple comparisons. After that, we assessed the diagnostic accuracy of the combination of splenic perfusion, spleen size, age, gender, and the presence or absence of hepatitis B and hepatitis C viral infection in detecting liver fibrosis, using stepwise regression and receiver operating characteristic analysis.

RESULTS

Significant differences (P < 0.05) in MTT were observed in comparisons between fibrosis stages F0 and F4, between F1 and F4, and between F2 and F4. Significant differences (P < 0.05) in R were observed in comparisons between F0 and F4, and between F1 and F4. Considering the presence or absence of hepatitis B and C viral infection along with MTT and R, the areas under the receiver operating characteristic curves were 0.89 for ≥F1, 0.83 for ≥F2, 0.82 for ≥F3, and 0.82 for F4.

CONCLUSION

Splenic MTT and spleen size are helpful in assessing liver fibrosis.

Usefulness of three-dimensional magnetic resonance cholangiopancreatography with partial maximum intensity projection for diagnosing autoimmune pancreatitis

PURPOSE

To compare three-dimensional magnetic resonance cholangiopancreatography (MRCP) with/without partial maximum intensity projection (MIP) and endoscopic retrograde cholangiopancreatography (ERCP) in patients with autoimmune pancreatitis (AIP).

MATERIALS AND METHODS

Three-dimensional MRCP and ERCP images were retrospectively analyzed in 24 patients with AIP. We evaluated the narrowing length of the main pancreatic duct (NR-MPD), multiple skipped MPD narrowing (SK-MPD), and side branches arising from the narrowed portion of the MPD (SB-MPD) using four MRCP datasets: 5 original images (MIP₅), 10 original images (MIP₁₀), all original images (full-MIP), and a combination of these three datasets (a-MIP). The images were scored using a 3- or 5-point scale. The scores of the four MRCP datasets were statistically analyzed, and the positive rate of each finding was compared between MRCP and ERCP.

RESULTS

The median scores for SB-MPD on MIP₅ and a-MIP were significantly higher than those on MIP₁₀ and full-MIP. In other words, partial MIP is superior to full-MIP for visualization of detailed structures. The positive rate for SB-MPD on full-MIP was significantly lower than that on ERCP, whereas the positive rate on MIP₅, MIP₁₀, and a-MIP was not significantly different from that on ERCP. Moreover, the positive rate for NR-MPD and SK-MPD on the MRCP images was significantly higher than that on the ERCP images.

CONCLUSION

Partial MIP is useful for evaluating the MPD and is comparable with ERCP for diagnosing AIP.

Marked and rapid regression of hepatic amyloid deposition in a patient with systemic light chain (AL) amyloidosis after high-dose melphalan therapy with stem cell transplantation

A 52-year-old woman with a high serum alkaline phosphatase (ALP) level underwent a liver biopsy, which showed diffuse heavy deposition of Aκ amyloid, and was diagnosed as having immunoglobulin light chain (AL) amyloidosis. Although she received high-dose melphalan with stem cell transplantation and achieved a hematologic complete response (CR), her ALP level began to increase one year after treatment. Further examinations revealed that she was still in a CR state with dominant bone-type ALP, and re-biopsied liver specimens demonstrated marked regression of amyliod deposition, providing important evidence that the turnover of hepatic amyloid proteins can actually occur more rapidly than previously thought.

Liver dysfunction and thrombocytopenia diagnosed as intravascular large B-cell lymphoma using a timely and accurate transjugular liver biopsy

A 72-year-old man suffered from paraparesis with a sensory impairment and bladder and rectal disturbances. Magnetic resonance imaging T2-weighted images depicted a high-intensity lesion in the spinal cord that was consistent with myelitis. A blood examination revealed severe thrombocytopenia and liver dysfunction. No malignant cells were detected by peripheral smears or bone marrow biopsy. Systemic computed tomography detected hepatosplenomegaly and ascites but no lymphadenopathies. Transjugular liver biopsy (TJLB) safely confirmed a diagnosis of intravascular large B-cell lymphoma (IVLBCL), and the patient achieved a complete response following treatment with an appropriate chemotherapy. TJLB is therefore a timely and accurate diagnostic approach for IVLBCL, especially when a bleeding tendency and ascites are noted.

Characteristic magnetic resonance features of focal autoimmune pancreatitis useful for differentiation from pancreatic cancer

PURPOSE

To identify characteristic magnetic resonance (MR) features of focal autoimmune pancreatitis (f-AIP) useful for differentiation from pancreatic cancer (PC).

METHODS

We retrospectively analyzed MR imaging findings of 20 f-AIP lesions and 40 PC lesions smaller than 40 mm in diameter. On fat-suppressed T2-weighted images and dynamic contrast-enhanced fat-suppressed T1-weighted images (DCE-T1WI), we classified MR features of internal signal intensity for each lesion into homogeneous, speckled, or target type. We assessed the sensitivity, specificity, and accuracy of these findings in the diagnosis of f-AIP. We also investigated the incidence of previously reported findings for differentiation between f-AIP and PC.

RESULTS

Speckled enhancement within a hypointense or isointense lesion on pancreatic phase DCE-T1WI (speckled type) was observed more frequently in f-AIP than in PC, with high sensitivity, high specificity, and high accuracy. Hypointensity to hyperintensity surrounding a less enhanced focal area on DCE-T1WIs (target type) and upper stream main pancreatic duct dilatation were observed more frequently in PC than in f-AIP.

CONCLUSION

Speckled enhancement inside an f-AIP lesion on pancreatic phase DCE-T1WI was useful for differentiation from PC.

Chronic gastritis in the setting of autoimmune pancreatitis

Autoimmune pancreatitis (AIP) is a recently recognized disease entity. In some patients, this disease is associated with other inflammatory diseases. In this study, we aimed to elucidate the pathologic characteristics of AIP-associated gastritis (AIP-G). We evaluated and compared the pathologic findings and immunohistochemical expressions of immunoglobulin G (IgG)4 and IgG in gastric biopsy specimens from 13 AIP-G patients with those from patients of 2 control groups. We divided the AIP-G patients who did not receive steroid therapy [AIP-G-ST(-)] into the following 2 groups: without Helicobacter pylori (HP) infection [AIP-G-HP(-)] and with HP infection [AIP-G-HP(+)]. The control groups comprised 19 patients who were diagnosed with chronic active gastritis associated with HP infection and 7 patients with nonsteroidal anti-inflammatory drug-induced gastritis. We classified the findings for the gastric mucosa into those for the upper and the lower lamina propria. The characteristic finding of AIP-G groups was diffusely lymphoplasmacytic infiltration in the lamina propria. The IgG4-positive plasma cell/IgG-positive plasma cell ratios (IgG4/IgG ratios) in both the upper and lower lamina propria in the AIP-G-ST(-) groups were predominantly higher than the corresponding values in the other groups. In the AIP-G-ST(-) groups, the IgG4/IgG ratio in the lower lamina propria was predominantly higher than that in the upper lamina propria, irrespective of the HP status. In conclusion, diffuse lymphoplasmacytic infiltration in the lamina propria and increased IgG4/IgG ratio in the gastric mucosa (notably in the lower lamina propria) may be the characteristic findings of AIP-G.

Intestinal angina due to atherosclerosis in a 45-year-old systemic lupus erythematosus patient

We report a patient with systemic lupus erythematosus (SLE) who developed progressive emaciation and postprandial abdominal pain with a 27-year history of corticosteroid treatment. The patient was diagnosed as having intestinal angina based on computed tomography that showed severe stenosis of the superior mesenteric artery (SMA) in addition to complete occlusion of the celiac and inferior mesenteric arteries. Histopathology of the SMA and abdominal aorta showed atherosclerosis with no vasculitis or thrombus formation. Intestinal angina should actively be considered as a possible cause of recurrent abdominal pain in SLE patients, particularly in those with a long history of disease.

A phase II study of doxorubicin plus paclitaxel followed by weekly paclitaxel as neoadjuvant chemotherapy for breast cancer (SBCCSG-07)

11103

Background: The primary aim of this study was to estimate the rate of clinical and pathologic response to preoperative doxorubicin and paclitaxel followed by weekly paclitaxel in stage II /III breast cancer. Secondary objective included the determination of time to progression, over all survival, the rate of breast conservation surgery, feasibility and safty. Saitama breast cancer clinical study group-07 study (SBCCSG-07; CTR:UMIN000000504) Methods: Patients were treated with 50 mg/m2 of doxorubicin intravenously and 150 mg/m2 of paclitaxel both administered intravenously on day 1 every 21 days for 4 courses followed by 80 mg/m2 of paclitaxel administered intravenously on day 1 every week for 12 courses(AP-wP). The rate of pathological, clinical response and breast conserving surgery and adverse events (CTCAE ver.3.0) were analyzed in stage II /III breast cancer. Results: From December 2005 to August 2006, 40 planned patients have been enrolled. One patient canceled chemotherapy for interstitial pneumonia. 16 patients have finished their treatment, received surgery and are evaluable for response. Clinical response rate was 81.2% (50.0%CR; 31.2%PR). Stable disease and progressive disease occurred in 2 (12.5%) patients and 1 (6.3%) patient. Four patients (25%) had pathological complete response. Conclusions: Preliminary results indicate that the AP-wP regimen feasible and very active as induction chemotherapy of operable breast cancer. Updated data including evaluation of biological markers will be presented at the meeting.

No significant financial relationships to disclose.

The utility of an investigational real-time RT-PCR assay system for the detection of micrometastases in sentinel lymph nodes of breast cancer confirmed by 0.2 mm histological interval analysis

10560

Background: Comparison between real-time RT-PCR and histological analysis for the detection of lymph node metastasis in breast cancer patients is difficult because of the necessary use of different tissue for the two tests. In order to minimize this challenge this study used histology sections taken every 0.2 mm and all tissue between the sections was analyzed by real-time RT-PCR. Methods: 129 Lymph nodes (LNs) were obtained by Sentinel LN biopsy and/or axillary dissection from 80 breast cancer patients. All LNs were cut in half. One half of each LN was used for the routine intra-operative diagnosis. The other half was used for the 0.2mm histological interval analysis. All 10μm sections cut for histology at 0.2 mm intervals were analyzed using frozen section H&E under a light microscope. All remaining tissue between the sections used for histological analysis was assayed by real-time RT-PCR using the genetic markers mammaglobin and cytokeratin-19 (investigational GeneSearch Breast Lymph Node Assay, Veridex, LLC, Warren, NJ, USA). Cutoffs were pre- set for the real-time RT-PCR to detect only metastasis greater than 0.2 mm. Results: Compared to the histological diagnosis using 0.2 mm interval frozen sections, the real-time RT-PCR results were as follows; sensitivity of 100.0% (34/34), specificity of 93.7% (89/95) and overall accuracy of 95.3% (123/129). Conclusions: These data suggest by utilizing the 0.2 mm histological interval analysis, sampling discrepancies are minimized and a high level of sensitivity and overall accuracy is seen for the real-time RT-PCR assay. Assay specificity calculations may be less than 100% due to interpretation challenges in frozen section histology, especially in the cases of smaller metastases and/or lobular cancer, causing a small percentage of clinically relevant metastasis to be missed.

[Table: see text]

Serial assessment of left ventricular function in various patient groups with Tl-201 gated myocardial perfusion SPECT

PURPOSE

The present study was performed to assess stress-related left ventricular (LV) function variations in various patient groups and to determine if they were affected by sex or the type of stress experienced. We used thallium (Tl)-201 gated myocardial perfusion single-photon emission computed tomography (SPECT) for the analysis.

MATERIALS AND METHODS

A total of 270 patients were examined by electrocardiography-gated myocardial perfusion SPECT imaging to assess LV function. After injection of Tl-201 at a dose of 111 MBq at peak stress, SPECT scans were acquired at 10 min (after stress) and 3 h (rest) after injection on a three-headed camera.

RESULTS

In the normal perfusion group, the mean LV ejection fraction (LVEF) was significantly higher, and both the end-diastolic volume index (EDVI) and end-systolic volume index (ESVI) were significantly lower in women than in men (P < 0.05). Poststress stunning occurred in 29 of 98 patients (30.0%) in the ischemia group and in 42 of 90 patients (46.7%) in the fixed group. There was a significant difference in poststress stunning between bicycle ergometer stress and dipyridamole stress (P < 0.05).

CONCLUSION

In patients with normal perfusion, LVEF, EDVI, and ESVI determined by gated Tl-201 SPECT should be corrected for sex. In addition, the influence of the type of stress should be considered when assessing stress-related LV function variations.

Update results of FEC followed by docetaxel neoadjuvant trials for primary breast cancer

This study has been initiated to evaluate the safety, clinical and pathologic response as well as the relation of response (pCR or non-pCR) and survival (overall and relapse-free) of fluorouracil, epirubicin and cyclophosphamide (FEC) followed by docetaxel (DOC) as preoperative chemotherapy in patients with operable breast cancer. Japanese patients with primary breast cancer, Tlc-3N0M0 or T1-3NIM0, age 20-60, PS 0-1 were included in this study. Preoperative chemotherapy consisted of 4 cycles of FEC (500 mg/m(2), 100 mg/m(2), 500 mg/m(2)) every 3 weeks followed by 4 cycles of DOC (75 mg/m(2)) every 3 weeks. Since June 2002, 200 patients were enrolled in this study, and the time of this interim analysis, 80 patients were evaluable for safety and clinical efficacy. The overall clinical response rate was 71.4% (14% CR, 44% PR, 42% SD/PD), and the only G3,4 toxicities, neutropenia and febrile neutropenia were observed in 54% and 14% of patients, respectively. Eighty nine patients were evaluable for pathologic response by central review. Pathologic response was evaluated among invasive tumors on multiple cross-section specimens based on a modified version of the Japanese grading system for Japanese Breast Cancer Society. The pathologic response rate was 17%. In this ongoing trial, FEC followed by DOC was active and well tolerated.

Clinical significance of VEGF-C status in tumour cells and stromal macrophages in non-small cell lung cancer patients

Recent experimental studies have revealed that tumour-associated stromal macrophages as well as tumour cells express vascular endothelial growth factor C (VEGF-C), which plays important roles in lymphangiogenesis, which is a critical factor in the progression of many malignant tumours including non-small-cell lung cancer (NSCLC). However, no clinical study on VEGF-C expression in both stromal macrophages and tumour cells has been reported, and we conducted the present study to address the issue in resected NSCLC. A total of 206 patients with completely resected pathologic stage I-IIIA NSCLC were retrospectively reviewed. Expression of VEGF-C in primary lung tumour was assessed immunohistochemically. Expression of VEGF-C in tumour cells was high in 125 patients (60.7%), and that in stromal macrophages was positive in 136 patients (71.2%). The status of VEGF-C in tumour cells or in stromal macrophages was not correlated with nodal status or angiogenesis. The 5-year survival rate of high tumoral VEGF-C patients (60.7%) was significantly lower than that of low tumoral VEGF-C patients (39.3%) (P=0.046), and a multivariate analysis confirmed that tumoral VEGF-C status was a significant and independent prognostic factor. Moreover, tumour showing high VEGF-A and VEGF-C expression in tumour cells showed the poorest prognosis (5-year survival rate, 45.1%). The status of VEGF-C in stromal macrophages was not correlated with the prognosis. In conclusion, tumoral VEGF-C status, not stromal VEGF-C status, was a significant prognostic factor in resected NSCLC.

Successful treatment of arterial priapism with radiologic selective transcatheter embolization of the internal pudendal artery

We report our successful treatment of arterial priapism by means of radiologic selective transcatheter embolization of the internal pudendal artery using an absorbable gelatin sponge (Spongel).

Clinical application of a curved nitinol stent-graft for thoracic aortic aneurysms

PURPOSE

To evaluate the clinical efficacy of a curved nitinol stent-graft for repair of thoracic aortic aneurysms.

METHODS

The Matsui-Kitamura stent-graft (MKSG), composed of a self-expanding nitinol stent and polyester fabric, was shaped to match the aortic curvature of 11 patients (6 men; mean age 72.6 years, range 33-90) with 6 true and 5 false aneurysms of the distal arch or proximal descending aorta. The delivery system was an 18 or 20-F J-shaped sheath combined with a preloader-type introducer. The original mean proximal neck length was 16.4 mm, but 4 patients received an axilloaxillary bypass to lengthen the neck. Although the mean corrected proximal neck length was 21.9 mm (overall), 5 cases still had proximal necks <15 mm long.

RESULTS

All curved MKSGs were successfully deployed in the correct position and fitted to the curvature of the aortic arch, achieving complete aneurysm exclusion in 8 (73%) cases. The other 3 repairs displayed early endoleaks; 1 received an additional MKSG, but the other 2 are being observed. Thirty-day mortality was 0%. One patient developed transient renal failure requiring hemodialysis; no neurological complications were observed.

CONCLUSIONS

Endovascular repair of thoracic aortic aneurysms using curved MKSGs appears to be feasible and clinically effective. A tighter fit of the device to the curvature of the aortic arch may exclude distal arch aneurysms despite a short proximal neck.

Parotid gland lesions: diagnosis of malignancy with MRI and flow cytometric DNA analysis and cytology in fine-needle aspiration biopsy

BACKGROUND

The purpose of this study was to assess the capability of magnetic resonance imaging (MRI) and cytology and flow cytometric (FCM) deoxyribonucleic acid (DNA) analysis in fine-needle aspiration biopsy (FNAB)-derived materials for diagnosing malignancy of the parotid lesions and the efficacy of FCM analysis in FNAB.

METHODS

Magnetic resonance imaging findings and FCM results (ploidy and S + G2 + M phases [S + G2M] fraction) and cytology in FNAB-derived materials in 26 patients with 26 parotid lesions (12 benign lesions, 14 malignancies) were assessed for predicting malignancy. Flow cytometric results in aspirates were compared with those in surgically resected tissues.

RESULTS

When a single predictor was used, cytology (92% accuracy) was most accurate for malignancy, followed by ill-defined margin (88% accuracy) and aneuploidy (88% accuracy). The combination of FCM and cytology raised the rate of sufficient materials from 92% to 100% and accuracy from 92% to 96% compared with cytology alone. The same highest accuracy (96%) was obtained with the combination of the ill-defined margin or other findings such as cytology, aneuploidy, or a high (S + G2M) fraction (6% <). Deoxyribonucleic acid ploidy in the FNAB showed full agreement with that in the surgical specimens. Receiver operating characteristic curves showed that the diagnosis of malignancy with (S + G2M) fraction in FNAB was superior to that in surgical specimens, but no significant difference was noted.

CONCLUSIONS

A combination of MRI findings, cytology, and FCM results is optimal for diagnosing malignancies of the parotid lesions, and FNAB may replace the surgical specimens in FCM analysis.

Removal of disperse dyes by the fungus Cunninghamella polymorpha

A disperse dye-removing fungus, Cunninghamella polymorpha, was isolated from soil. C. polymorpha efficiently removed an average 93% of 17 tested disperse dyes in 120 h, and 90% of C. I. Disperse Blue 60 was removed even at a high concentration of 500 mg/l. The dye removal was due to the sorption of dye to the fungal cells.

Removal of a dimeric form of surfactant protein C from mouse lungs: its acceleration by reduction

Clearance of hydrophobic surfactant-associated protein C (SP-C) and its dimeric form ([SP-C]2) was investigated. SP-C and [SP-C]2 obtained from proteinosis patients were fluorescently labeled and were instilled into mouse lungs as lipid-protein complexes. [SP-C]2 was removed more slowly than SP-C, with apparent half-lives of 30 and 18 h, respectively. A significant amount of [SP-C]2 was removed as SP-C, and the conversion rate was 0.22 micrograms.h-1.mouse-1. By correcting the removal as SP-C, we obtained 38 h for a possible half-life of [SP-C]2. Conversion from SP-C to [SP-C]2 seemed very slow. Decrease in glutathione (GSH) in the lung inhibited the conversion of [SP-C]2 to SP-C and GSH-treatment of liposomes accelerated clearance of [SP-C]2. These results suggest that the removal of [SP-C]2 from lung is accelerated by reduction and that GSH acts as a reducing agent in the lung.

Pathobiology of the senescence-accelerated mouse (SAM)

Routine postmortem examinations and the pathobiological features revealed by systematically designed studies have shown several pathologic phenotypes that are often characteristic enough to differentiate among the various SAM strains: senile amyloidosis in SAMP1, -P2, -P7, -P9, -P10, and -P11; secondary amyloidosis in SAMP2 and -P6; contracted kidney in SAMP1, -P2, -P10, and -P11; immunoblastic lymphoma in SAMR1 and -R4; histiocytic sarcoma in SAMR1 and -R4; ovarian cysts in SAMR1; impaired immune response in SAMP1, -P2, and -P8; hyperinflation of the lungs in SAMP1; hearing impairment in SAMP1; degenerative temporomandibular joint disease in SAMP3; senile osteoporosis in SAMP6; deficits in learning and memory in SAMP8 and -P10; emotional disorders in SAMP8 and -P10; cataracts in SAMP9; and brain atrophy in SAMP10. These are all age-associated pathologies, the incidence and severity of which increase with advancing age. The SAM model in which these pathobiological features have been carefully monitored will be a valuable tool in the clarification of the pathogenic mechanisms of age-associated pathologies and in the research for effective methods to modulate or ameliorate these pathologies.

Age-related changes in lung structure and function in the senescence-accelerated mouse (SAM): SAM-P/1 as a new murine model of senile hyperinflation of lung

Age-related changes in lung structure and function were investigated in murine models of accelerated senescence (SAM-P/1) and of normal aging (SAM-R/1). In morphometric studies, most of the parameters examined, including lung volume, mean linear intercept, total alveolar duct air volume, and total alveolar air volume, began to increase and the internal surface area per unit lung volume and total elastic fiber length per unit lung volume began to decrease from 2 months of age, and these changes continued to progress up to 10 months of age in SAM-P/1. In SAM-R/1, there were no significant changes in these parameters from 2 to 6 months of age, thereafter slight but steady changes were observed up to 25 months of age. Thus, significant differences in these parameters between SAM-P/1 and SAM-R/1 became evident in mice 6 to 17 months of age. Internal surface area and total elastic fiber length showed no age-related changes after 2 months of age, and total alveolar air volume showed no age-related changes after 6 months of age in either strain. All morphometric parameters examined showed similar levels at 17 months of age in SAM-P/1 and 25 months of age in SAM-R/1. Histologic observations revealed no evidence of destruction of the alveolar wall or elastic fibers in the lung.(ABSTRACT TRUNCATED AT 250 WORDS)

Neonatal tolerance induction in the thymus to MHC-class-II-associated antigens. V. Thymus medulla and the site for deletional signaling achievement in Mls tolerance

Intravenous (i.v.) injection of Mls-1a peritoneal cavity (PerC) cells from (BALB/c x AKR)F1 (Mls-1b/a, H-2d/k) mice into newborn BALB/c (Mls-1b, H-2d) mice induced thymus cell tolerance by one week of age, accompanied by V beta 6+ cell elimination. The tolerant state is associated with intrathymic chimerism with MHC-class II(IA+) cells, confluent in the medulla and scattered in the cortex. To clarify the anatomical site for the deletional signaling, we injected Mls-1a PerC cells directly into the thymus lobe of BALB/c mice on the day of birth. Thus induced tolerant state was limited to the injected lobe and there was no penetration to the contralateral lobe. The tolerant state lasted less than 2 weeks, by which time donor-derived Ia+ cell had disappeared from the thymus. Thus, PerC cells seem to have little self-renewing ability. One week after the intrathymic injection of a small amount (0.3 microliter) of PerC cell suspension in several different sites, the thymus lobes were removed without killing the mice and serial cryostat sections were cut and stained immuno-histochemically for analysis of the donor cell distribution. Four weeks later, the functional activities of peripheral T cells in the spleens of the treated mice were tested. These experiments revealed that inoculated cells lodging in the medulla, but not in the cortex, induced tolerance to the Mls determinants. Target thymocytes for negative signaling are probably located in the medulla/juxta-medullary area in the thymus. Data are discussed in relation to Mls-bearing stroma cells in the thymus.

[A case of thyroid medullary carcinoma-like tumor of the lung with amyloid stroma]

A 58-year-old man with history of productive cough and mild exertional dyspnea for several years was admitted to our hospital because of abnormal shadow on chest radiograph. Bronchofiberscopic examination revealed a polypoid tumor almost completely obstructing the right main bronchus. Bronchoscopic biopsy specimens showed amyloid-like deposits in the connective tissue surrounded by epithelium-like tumor cells with squamous metaplasia, but no diagnostic findings. Malignant tumor was suspected and right upper lobectomy was performed. The surgical specimen revealed nests of tumor cells surrounded by amorphous eosinophilic substance, which was confirmed to include amyloid fibrils by electron microscopy. A few tumor cells contained argyrophil granules by Grimelius staining, and some showed PAP staining for calcitonin. There was no evidence of involvement of other organs including the thyroid gland during the four year postoperative follow-up period. This case was diagnosed as thyroid medullary carcinoma-like tumor of the lung, which is a bronchopulmonary carcinoid-related tumor.

Neonatal tolerance induction in the thymus to MHC-class II-associated antigens. IV. Significance of intrathymic chimerism of blood-born Ia+ cells in Mls tolerance

The significance of thymus cell chimerism in the induction and maintenance of tolerance was investigated. Mls-1b BALB/c mice were neonatally tolerized by the intravenous administration of either bone marrow (BM) cells or peritoneal cavity (PerC) cells from Mls-1b/a (BALB/c x AKR) F1 mice. Tolerance was long-lasting in the BM cell group, but transient in the PerC cell group, probably because PerC cells lack hemopoietic stem cells required for a continuous supply of tolerance-inducing cells. The degree of anti-Mls-1a responsiveness of these BALB/c thymus cells was correlated with the degree of intrathymic distribution of the inoculated F1 cells. The effect of BM cell inoculation, resulting in a year-long deletion of Mls-1a-reactive V beta 6-bearing T cells is in marked contrast to that of PerC cell inoculation which causes only a transient loss of V beta 6+ mature thymocytes (for about 1 week after birth). This functional profile of the tolerant state correlates well with the degree and persistence of the intrathymic presence of F1 type Ia+ cells. The long-lasting presence of donor-derived cells throughout the thymus tissue in the BM cell group is also in marked contrast to the early disappearance of Ia+ cells (within 2-3 weeks) from the cortex and then from the medulla in the PerC cell group, although these Ia+ cells were once spread throughout the thymus tissue 4 days after the tolerance-inducing cell inoculation. Taken together with a failure to induce consistent unresponsiveness to Mls-1a determinants in Mls-1b thymocytes regenerating in Mls-1a-thymic epithelial environments, all the above data indicate that intrathymic chimerism caused by hemopoietic stem cell-derived MHC-class II-bearing cells is a requisite for the induction and maintenance of unresponsiveness by means of clonal deletion in experimentally as well as naturally induced tolerance to Mls determinants.

[An epidemiologic study on patients with lung disease, using a data base management system and the histopathologic diagnosis]

A new pathologic data base management system was introduced in the Section of Pathology, Clinical Laboratory, of this hospital for an efficient sorting and searching past data and for the rapid epidemiological study of them. By the use of this system, the incidence and the age and sex distribution of various diseases were studied in a total of 1,264 patients received pathological examination for surgically operated specimens or biopsied materials at the Chest Disease Research Institute Hospital, Kyoto University, from January, 1986 to December, 1988. A gradual increase in the number of frozen section samples of surgically removed organs and of open lung biopsies was noted during this period. Adenocarcinoma, squamous cell carcinoma, small cell carcinoma and large cell carcinoma amounted to 42.5%, 32.9%, 12.2%, and 7.5% of primary lung cancers, respectively. The male-to-female ratio of patients with primary lung cancers was 2.9:1 but there was no significant difference in the age distribution among four types of the primary cancers in both sexes. Two hundred and ninety nine (32.6%) patients were diagnosed as non-neoplastic lung diseases: 121 infectious (13.2%), 69 granulomatous (7.5%), 62 pulmonary fibrotic (6.8%) and 47 miscellaneous non-neoplastic (5.1%) diseases.

Isolation and partial characterization of human low molecular weight protein associated with pulmonary surfactant

A low molecular weight (MW) protein was isolated from the bronchoalveolar lavage fluid of a patient with alveolar proteinosis. The protein was isolated on DEAE-cellulose and CM-cellulose columns by a cross-reaction with the monoclonal antibody against pig low MW protein (15 kDa) used as a marker. Acidic ethanol-soluble proteins obtained from the fractions eluted by 0.09 to 0.16 M NaCl concentration from the CM-cellulose column migrated mainly as a 15-kDa band in the SDS-PAGE system without urea but mainly as a 5-kDa band in a system with 8 M urea. The isoelectric point of the protein was pH 10 to 11, and it contained a large proportion of hydrophobic amino acids (72%), especially leucine (17%). The arginine content was also high (9%). Two monoclonal antibodies were raised against this low MW protein, and immunohistochemical studies revealed that the antigen was located in the inclusions of alveolar wall cells in normal lungs and in lungs from a patient with alveolar proteinosis. These results indicate that the low MW protein originates from lamellar inclusions of alveolar wall cells (possibly type II epithelial cells) and is secreted into alveolar spaces.