Therapeutic efficacy of humanized monoclonal antibodies targeting dengue virus nonstructural protein 1 in the mouse model

Dengue virus (DENV) which infects about 390 million people per year in tropical and subtropical areas manifests various disease symptoms, ranging from fever to life-threatening hemorrhage and even shock. To date, there is still no effective treatment for DENV disease, but only supportive care. DENV nonstructural protein 1 (NS1) has been shown to play a key role in disease pathogenesis. Recent studies have shown that anti-DENV NS1 antibody can provide disease protection by blocking the DENV-induced disruption of endothelial integrity. We previously demonstrated that anti-NS1 monoclonal antibody (mAb) protected mice from all four serotypes of DENV challenge. Here, we generated humanized anti-NS1 mAbs and transferred them to mice after DENV infection. The results showed that DENV-induced prolonged bleeding time and skin hemorrhage were reduced, even several days after DENV challenge. Mechanistic studies showed the ability of humanized anti-NS1 mAbs to inhibit NS1-induced vascular hyperpermeability and to elicit Fcγ-dependent complement-mediated cytolysis as well as antibody-dependent cellular cytotoxicity of cells infected with four serotypes of DENV. These results highlight humanized anti-NS1 mAb as a potential therapeutic agent in DENV infection.

DENV comprising four serotypes has a complicated pathogenesis and remains an unresolved global health problem. To date, supportive therapy is the mainstay for treatment of dengue patients. Despite a licensed Sanofi vaccine and ongoing clinical trials, more effective vaccines and/or licensed therapeutic drugs are required. Therapeutic mAbs are a potential tool to treat many epidemic diseases because of their high target specificity. Humanized anti-NS1 mAbs can recognize the NS1 from all four serotypes of DENV without danger of inducing ADE. In the DENV infection mouse model, we demonstrate that humanized NS1 mAbs have therapeutic benefits such as reducing DENV-induced prolonged bleeding time and skin hemorrhage. In vitro mechanistic studies showed a reduction of NS1-induced vascular permeability and an increase in cytolysis of DENV-infected cells. Our results showed that humanized anti-NS1 mAbs show strong potential for development toward clinical use.

Successful outpatient treatment of renal vein thrombosis by low-molecular weight heparins in 3 patients with nephrotic syndrome

Renal vein thrombosis (RV Thromb) is a serious complication ofnephrotic syndrome. Anticoagulation is usually recommended as the treatment of choice. This study reports 3 nephrotic patients diagnosed to have RVThromb combined with thromboembolic events. Low-molecular weight heparin (LMWHep) was given subcutaneously every 12 hours following the diagnosis of RVTromb, which continued at the outpatient clinic after an average of 11 in-hospital days. The patients visited the nephrology outpatient clinic every other week and underwent magnetic resonance image (MRI) studies at 6-week intervals for follow-up of patency of the involved renal vein. LMWHep was discontinued when MRI showed this patency. The average outpatient treatment period was 74 days. There was no recurrent RVThromb in the follow-up course of 6 months after discontinuation of LMWHep. Kidney function was preserved, as indicated by image studies and serial renal function tests. LMWHep produced a more predictable anti-coagulant effect, a superior bioavailability, a longer half-life and a dose-independent effect than unfractionated heparin and coumadin. These benefits made the outpatient treatment of RVThromb possible. Our report recommends outpatient treatment of RVThromb by LMWHep because it is feasible, effective and safe.

An improved procedure for catheterization of the thoracic spinal subarachnoid space in the rat

Catheterization of the subarachnoid space provides a convenient means to deliver drugs to, or collect cerebrospinal fluid from, the spinal cord in animal experiments, and has been instrumental to our understanding of spinal mechanisms that underlie anesthesia, analgesia, or cardiovascular regulation. Experience gained over the years has revealed several shortcomings of this technique. We report a procedure that encompasses the benefits of direct subarachnoid catheterization of the rat thoracic spinal cord but circumvents the known shortcomings. An intrathecal catheter was fabricated with a small silicon bead at one end of a PE-10 catheter, which was cannulated with a 4/0 suture that served as a guide. Using the L-shape hook of the suture guide as an anchorage, the catheter was advanced into the subarachnoid space until the silicon bead was lodged on a drilled hole (2 x 2 mm) over the lamina proper on the T13 vertebrae. With less surgical trauma, greater precision of placement and firmer anchorage of the catheter, less leakage of cerebrospinal fluid, and minimal mortality or morbidity, our modified procedure for catheterization of the thoracic spinal subarachnoid space in the rat compared favorably to previously reported methods.

Symptomatic giant Müllerian duct cyst in an infant: radiographic and CT findings

We report an unusual case of Müllerian duct cyst in an 8-month-old infant who presented with frequent vomiting and recurrent urinary tract infections. Computed tomography showed a midline giant cyst in the pelvic floor. Delayed enhanced computed tomography demonstrated contrast filling of the cyst, indicating a communication with the urotract. Subsequent cystourethrogram and surgery confirmed a giant Müllerian duct cyst.

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.

Infradiaphragmatic pulmonary sequestration combined with cystic adenomatoid malformation: unusual postnatal computed tomographic features

We present a surgically proven case of infradiaphragmatic pulmonary sequestration combined with cystic adenomatoid malformation. Prenatal magnetic resonance imaging revealed a well-defined hyperintense mass with a hypointense septum in the left infradiaphragmatic region. Postdelivery computed tomography (CT) and 3-month follow-up CT showed replacement of intralesional cystic areas by solid content. Such unusual postnatal CT changes, to our knowledge, have not been previously documented.

The high value of high-resolution computed tomography in predicting the activity of pulmonary tuberculosis

SETTING

A 2500-bed medical centre in southern Taiwan.

OBJECTIVE

To study the clinical value of high-resolution computed tomography (HRCT) in predicting the activity of pulmonary tuberculosis (TB).

DESIGN

HRCTs were performed prospectively in 148 patients whose chest radiographs (CXRs) showed highly suspicious signs of pulmonary TB, predominantly upper lung field infiltration. The HRCT findings, interpreted independently by a pulmonologist and a radiologist, were used to predict the activity of pulmonary TB.

RESULTS

Pulmonologist-interpreted and radiologist-interpreted HRCTs showed high sensitivity (both 93%), specificity (83 vs. 88%), accuracy (86 vs. 90%), positive predictive values (76 vs. 83%) and negative predictive values (both 95%). Kappa statistic indicates good inter-reader agreement.

CONCLUSION

HRCT has a high value in predicting the activity of pulmonary TB. It is a useful tool in this regard when a patient with suspected pulmonary TB lacks microbiologic proof, when clinical condition makes invasive diagnosis impossible or when a patient has completed anti-tuberculosis treatment with no compatible unequivocal CXR.

Spontaneous rupture of hepatocellular carcinoma during pregnancy

BACKGROUND

Hepatocellular carcinoma associated with pregnancy is unusual.

CASE

A 33-year-old woman presented at 25 weeks' gestation with sudden, severe epigastric pain for 6 hours. Abdominal ultrasonography and magnetic resonance imaging showed multiple liver tumors with a small amount of ascites. Exploratory laparotomy revealed an unresectable ruptured liver tumor that was treated by packing. Although a biopsy was nondiagnostic, ultrasound-guided needle biopsy 6 days after cesarean delivery at 41 weeks' gestation showed hepatocellular carcinoma, which was treated with transarterial embolization. At 3.5 years posttherapy, both mother and infant are well.

CONCLUSION

Ruptured hepatocellular carcinoma during pregnancy is rare but should be included in the differential diagnosis of sudden, severe epigastric pain.

Endoscopic variceal ligation for intractable esophageal variceal bleeding in children with idiopathic extrahepatic portal vein occlusion: report of three cases

Extrahepatic portal vein occlusion (EPVO) is an important cause of extrahepatic portal hypertension and variceal hemorrhage in children. We report 3 children with a diagnosis of EPVO and intractable esophageal variceal bleeding who underwent scheduled endoscopic variceal ligation (EVL) and prophylactic propranolol therapy for eradication of esophageal varices. Complete variceal obliteration was achieved in all 3 children following 3-4 treatment sessions. There were no significant complications or gastrointestinal hemorrhage during a follow-up period of 9 to 31 months after variceal eradication. In conclusion, EVL and long-term propranolol prophylaxis is safe and effective in eradicating bleeding esophageal varices in children with EPVO.

Proton magnetic resonance spectroscopy of cerebral glioma after irradiation

BACKGROUND

Conventional magnetic resonance imaging (MRI) is commonly employed to assess cerebral gliomas after radiotherapy, but it cannot always differentiate tumor regrowth from post-irradiation changes. In this study, we utilized magnetic resonance spectroscopy (MRS) to evaluate changes in cerebral metabolites in patients with a cerebral glioma after irradiation.

METHODS

Over a period of 3 years, we performed MRS after MRI whenever soft tissue masses were found on magnetic resonance (MR) images. A total of 122 MR spectra of 58 patients was used for analysis. Spectral interpretations were based on integral values of the N-acetylaspartate (NAA) and choline (Cho) compounds relative to phosphocreatine/creatine (Cr).

RESULTS

Our MRS study showed that higher Cho/Cr ratios occurred in regrowing gliomas than for stable diseases (range, 0.9 to 9.5 vs. 0.4 to 2.1; mean, 3.0 vs. 1.2). A greater increment in the Cho/Cr ratio between successive studies was also noted in regrowing gliomas than for stable disease (range, 41% to 87% vs. < 32%). No significant differences in NAA/Cr ratios or lactate were found between these 2 groups. None of our patients exhibited abnormal MR spectra in the mirror area of the contralateral brain.

CONCLUSION

MRS provides valuable information about the metabolism of irradiated gliomas and can be used to exclude radiation encephalopathy of the contralateral brain. Cho is the most reliable indicator of a regrowing glioma. A high Cho/Cr ratio or substantial elevation in the Cho/Cr ratio between serial studies increases the likelihood of tumor regrowth. However, lower Cho/Cr ratios were inconclusive for determining if tumor regrowth or a stable process was occurring.

False aneurysm and mediastinal hematoma: complications of simultaneous transcatheter therapy for coarctation of the aorta and patent ductus arteriosus in an infant

We report an infant with intractable congestive heart failure caused by coarctation of the aorta, patent ductus arteriosus, atrial septal defect, and multiple muscular ventricular septal defects. He had received balloon angioplasty for dilating the aortic coarctation and a Gianturco coil for closing the ductus at a single therapeutic catheterization session at 4 months old. After balloon angioplasty, his heart failure had dramatically resolved. A false aneurysm and mediastinal hematoma were noted on the following day. The hematoma revealed total resolution 10 weeks later. He was asymptomatic throughout 12 months of follow-up.

Different management options for anaphylactoid purpura with intussusception: a case report

Intussusception is the most common surgical indication of anaphylactoid purpura. About 50% of cases are of the ileo-ileal type. Surgical intervention, rather than radiologic reduction, is preferable for older children suffering from anaphylactoid purpura with intussusception, where a lead point lesion is often found. The authors report a case of anaphylactoid purpura with intussusception with spontaneous reduction, and postulate that subsequent to relieving bowel-wall edema using antihistamine and steroid therapy, the ileo-ileal intussusception may spontaneously reduce.

Pulmonary valvular stenosis complicated by cerebrovascular accident and congestive heart failure in a young child

Pulmonary valvular stenosis (PS) with intact ventricular septum is a common congenital heart disease. In general, mild PS has a benign clinical course. However, in severe PS and some cases of moderate stenosis, increasing severity of the lesion may occur. The manifestations of either cerebrovascular accident (CVA) or congestive heart failure (CHF) are rarely reported in pediatric patients with PS. In this report, we describe a girl with severe PS complicated by seizures and sudden onset of hemiparesis at 13 months of age who developed CHF when 16 months old. CHF was cured after successful balloon valvuloplasty. She remained well without residual hemiparesis or recurrent seizures during the 1-year follow-up. Early balloon valvuloplasty should be emphasized in patients with severe PS, even if there are no significant clinical symptoms. With prompt balloon valvuloplasty, these complications can be effectively prevented.

Cystic malignant fibrous histiocytoma of the gastrocolic ligament

A case of malignant fibrous histiocytoma (MFH) of the gastrocolic ligament is presented. It appeared as a huge, thin walled cystic tumour in the upper abdominal cavity on CT. Barium studies showed splaying of the stomach and transverse colon by the mass. 1 year after resection of the cystic tumour, recurrence occurred at the greater curvature of the stomach and in the liver, with a cystic appearance similar to the primary tumour. To our knowledge, the CT appearance of primary cystic MFH of the gastrocolic ligament has not been previously documented.

Sonographic features of small-bowel intussusception in pediatric patients

OBJECTIVE

Small-bowel intussusception (SBI) for pediatric patients is unusual and difficult to diagnose preoperatively. This study sought to determine the sonographic findings of pediatric SBI.

METHODS

The sonographic features and surgical findings of 13 pediatric patients (7 boys, 6 girls; age range 4 months-15 years; average age 4 years and 2 months) with SBI encountered in the authors' hospital over a 12-year period were retrospectively reviewed.

RESULTS

Most of the patients presented with nonspecific symptoms, including vomiting, abdominal pain, and/or irritable crying. Sonographic screening in the emergency department revealed a doughnut or crescent-in-doughnut sign, or a multiple-concentric-rings sign for 11 of the 13 patients, and the lesions appeared short. Eight lesions were found in the paraumbilical or left abdominal regions. Sonographic measurement of the size of the lesions from these 11 patients ranged from 2 cm to 3.7 cm (average 2.77 cm). Subsequent barium enemas were performed for these 11 patients, none of which revealed colon lesions. Surgery revealed ileoileal intussusceptions for eight cases, jejunoileal for three, and jejunojejunal for the remaining two. Bowel ischemia or necrosis and pathologic lead points were demonstrated for seven and six patients, respectively, although none were recognized preoperatively.

CONCLUSIONS

Small-bowel intussusception is often over-looked due to nonspecific clinical presentations. Sonographic demonstration of a 2-3-cm sized, short, doughnut-like lesion, especially in the left abdomen or paraumbilical regions, should lead to strong suspicion of SBI.

Retrograde transcatheter occlusion of patent ductus arteriosus: preliminary experience in Gianturco coil technique without heparinization

BACKGROUND

The aim of this study was to report the initial experience of using the Gianturco coil (Cook Cardiology, Bloomington, Indiana) without heparinization to close patent ductus arteriosus (PDA).

PATIENTS AND METHODS

Forty consecutive patients (30 females, 10 males) underwent transcatheter closure of a PDA via the right femoral artery approach without heparinization. Patients ages ranged from 7 months to 55 years (median, 6.8 years); weights ranged from 7.8 65 kg (median, 18.3 kg). Twenty-one patients had cardiomegaly (n = 21), congestive heart failure (n = 10), or both (n = 10). The PDAs measured 0.8 4.5 mm (median, 2.6 mm) at the narrowest diameter; the mean Qp/Qs ranged from 1.0 2.6 (1.4 +/- 0.4). The helical diameter of the coil that we chose was 1.7 times the narrowest PDA diameter. The length of the coil was sufficient to produce 4 or 5 loops.

RESULTS

Successful coil placement was accomplished in all 40 patients. Thirty-five patients (87.5%) underwent single coil implantation, 2 patients (5%) had 2 coils, and 3 patients (7.5%) had 3 coils. Complete ductus occlusion was achieved in 80% of cases at the end of the procedure, while 8 patients had minimal shunt detected by aortography or echocardiography. The occlusion rate increased to 87.5% by the next day, 90% by 1 month, 92.5% by 3 months, 95% by 6 months, and 97.5% by 9 and 12 months. Only one asymptomatic patient had minimal residual shunt detected by color Doppler at 12 months follow-up. At a median follow-up of 17 months (range, 5 25 months), no patient had thromboembolism, endocarditis, coil migration, diminished femoral pulse or hemolysis.

CONCLUSION

Our preliminary results suggest that retrograde transcatheter closure of PDA with the Gianturco coil without heparinization is feasible, safe and efficacious. A single coil allowed complete occlusion of PDA 3 mm in diameter.

Reversible hypertensive retinopathy in a child with bilateral pheochromocytoma after tumor resection

Pheochromocytoma is very rare in children. We report a case of bilateral pheochromocytoma in a 12-year-old boy who had blurred vision due to hypertensive retinopathy. Abdominal ultrasound and computed tomography revealed bilateral suprarenal tumors. Resection of the bilateral tumors along with right total and left subtotal adrenalectomy were performed. Blood pressure and visual acuity returned to normal after surgery.

Pancreatic pseudocysts in children

BACKGROUND

Pancreatic pseudocysts in children are uncommon. The purpose of this study was to investigate the clinical course, image findings (with emphasis on sonograms), and outcome of 12 patients with pancreatic pseudocysts.

METHODS

From January 1986 to May 2000, 12 patients with a diagnosis of pancreatic pseudocysts were encountered in our hospital. There were 8 males and 4 females with ages ranging from 3 to 18 years.

RESULTS

The etiology was blunt abdominal trauma in all 12 cases. The cysts were detected from 3 to 57 days after injury, and the sizes ranged from 0.6 to 16 cm. Six patients received surgical treatment. External drainage was performed in 3 cases, subtotal pancreatectomy in 1, cystogastrostomy in 2. Initial serum amylase level correlated with neither the time to normalization (r = 0.354, p = 0.268), cystic appearance after trauma (r = 0.029, p = 0.933), nor resolution (r = 0.322, p = 0.309). Sonographic follow-up revealed that the disappearance of cysts was noted from 11 days to 10 months following injury. The size of the pseudocysts correlated with neither the time of detection (r = 0.284, p = 0.371) nor disappearance (r = -0.175, p = 0.586).

CONCLUSION

Serial sonogram examinations play an important role in monitoring the progress of pancreatic pseudocysts, which may develop even 57 days after injury. The size of pseudocysts correlated with neither the times of detection nor disappearance, and the initial serum amylase level correlated with neither the time to normalization nor cystic appearance after trauma.

Anomalous systemic arterialization to normal basal segments of the left lower lobe: helical CT and CTA findings

PURPOSE

The purpose of this work was to evaluate the helical CT and CT angiography (CTA) findings of anomalous systemic artery (ASA) to the basal segments of the left lower lobe (LLL).

METHOD

Three patients (two had hemoptysis, one was asymptomatic) with blotchy nodular density in the LLL revealed on chest radiographs underwent helical CT and CTA. Bronchoscopy was performed in two of these patients. Angiography and surgery were performed in one patient.

RESULTS

All three patients demonstrated characteristic helical CT and CTA findings including 1) a sigmoid-shaped ASA originating from the lower descending thoracic aorta, with a distal bulbous configuration and four arterial branches supplying the basal segments of the LLL; 2) absence of an interlobar pulmonary artery or presence of a small artery lateral to the truncus basalis; 3) engorged vascular markings in the basal segments of the LLL; and 4) normal tracheobronchial tree and lung parenchyma.

CONCLUSION

The findings in the present three cases suggest that the use of invasive studies such as angiography or bronchoscopy may be obviated in the diagnosis of ASA to the LLL because diagnosis can be provided through a clear set of criteria on helical CT and CTA.

Ipsilateral renal dysplasia with hypertensive heart disease in an infant with cutaneous varicella lesions: an unusual presentation of congenital varicella syndrome

A child with congenital varicella syndrome including cutaneous lesions and ipsilateral renal dysplasia with hypertensive heart disease is described. Varicella was contracted during the tenth week of gestation. Typical congenital varicella bullae, high titer of anti-varicella-zoster virus IgM, and a small right kidney were noted after birth. Hypertensive heart disease resulting from renal dysplasia occurred at 1 year of age. The cutaneous lesions and the dysplastic kidney involved the same dermatomes. Nephrectomy proved to be the treatment of choice for hypertension and congestive heart failure.

Echocardiographic evaluation of cardiac rhabdomyoma in infants and children

PURPOSE

The objective of this study was to demonstrate the clinical presentation, echocardiographic findings, and morbidity and mortality rates for cardiac rhabdomyoma in Chinese infants and children by using echocardiography.

METHODS

Two-dimensional echocardiography was performed at our institution from 1992 through 1999 on 12,800 children under 15 years of age. The diagnoses of cardiac rhabdomyoma were made primarily by echocardiography based on the presence of multiple tumors, cardiac tumors associated with tuberous sclerosis (TS), or histopathologic examination of surgical specimens. All patients were evaluated with 2-dimensional and Doppler echocardiography and then on follow-up examination every 3-6 months. Complete tumor regression was defined as no tumor visible by echocardiography. Partial tumor regression was defined as a decrease in tumor size of at least 15% from the previously measured size.

RESULTS

A total of 29 tumors were found in 11 patients, 8 of whom had either TS or a family history of TS in 1 or more first-degree relatives. There were 9 boys and 2 girls 1 day-6.5 years old; (mean, 1.1 years). Three patients (newborns with heart failure) died, 2 after emergency surgery and 1 of intractable heart failure. The remaining 8 patients were managed conservatively and monitored for a mean duration of 3.3 years. Follow-up studies revealed that, of the 22 tumors in these 8 patients, 7 completely regressed, 7 partially regressed, and 8 remained stable. Our results showed no relationship between the tumor location and the regression rate (p = 0.34).

CONCLUSIONS

Cardiac rhabdomyoma often presents in TS patients with no major arrhythmia or hemodynamic obstruction. However, in symptomatic neonates with or without TS, cardiac rhabdomyoma is usually fatal. Meticulous prenatal screening and routine echocardiographic examinations of patients with TS can reveal subclinical or clinically occult cardiac rhabdomyomas.

Healing of superior vena cava defect in mediastinal seminoma with invasion

We present an unusual case of mediastinal seminoma with direct intraluminal invasion into the superior vena cava (SVC) and extension to the right atrium. Magnetic resonance imaging demonstration of the SVC defect due to tumor invasion was important for determining treatment strategy because rapid posttherapeutic tumor regression may increase the risk of SVC rupture. Gradual healing of the SVC defect at the tumor entrance site was attained using a tailored treatment plan with radiotherapy and chemotherapy.

Meckel's diverticulum mimicking infantile colic: sonographic detection

We report a case of Meckel's diverticulum in a 6-month-old girl who presented with a 5-month history of chronic screaming but no symptoms or signs of intestinal obstruction. Infantile colic was the presumptive diagnosis. Abdominal sonography at 6 months of age demonstrated an abdominal mass with an anechoic center and a double-layered wall, surrounded by bowel loops. Abdominal CT and barium enema x-ray studies demonstrated nonspecific findings of a cystic mass with compression of adjacent bowel loops. Histologic examination of the resected mass revealed a Meckel's diverticulum with a perforation sealed off by the neighboring bowel and mesentery to form an inflammatory mass.

Clinical experience in the treatment of ulcer-induced gastric outlet obstruction in seven children

Peptic ulcer disease complicated with gastric outlet obstruction is rare in children. The experience in the treatment in children is limited. From 1987 to 1998, 7 children with gastric outlet obstruction due to peptic ulcer disease were encountered in our hospital. The 5 patients treated from October 1987 to May 1997 underwent truncal vagotomy, combined with pyloroplasty in 4 patients and antrectomy in 1. The indications for operation were failure of treatment with a histamine 2 (H2)-receptor antagonist. The remaining 2 patients, treated from June 1997 to October 1998, were successfully treated with oral omeprazole with or without the addition of antibiotics. These 2 patients had shorter hospital stays and could tolerate feeding earlier than those treated with truncal vagotomy. Although surgical treatment has merits in the management of children with peptic ulcer disease complicated with gastric outlet obstruction, in light of our cases we disclosed the trend toward intensive medical treatment.

Percutaneous transluminal angioplasty of renal artery stenosis in a child with hypertensive heart disease

A 1.5-year-old girl developed congestive heart failure 9 months after she presented with hypertension. The hypertension was caused by a renal artery stenosis. A short-segment stenosis at the ostium of the left renal artery was confirmed by arteriogram. After balloon angioplasty, the blood pressure and heart function returned to normal. Angioplasty had an excellent result of relieving hypertension and heart failure in this patient. Cathet. Cardiovasc. Intervent. 48:374-377, 1999.

Usefulness of pediatric flexible bronchoscopy in the early diagnosis and postoperation evaluation of vascular rings: report of three cases

Vascular rings are a diagnostic and therapeutic challenge for pediatricians. Many diagnostic modalities contribute to the detection of these rare congenital vascular anomalies. The role of flexible bronchoscopy is still being debated. We present 3 cases to emphasize the usefulness of pediatric flexible bronchoscopy (PFB) in the early diagnosis and postoperative evaluation of vascular rings. In patient 1, PFB was performed before conventional techniques were available. A right aortic arch with a retroesophageal aortic diverticulum and mirror-image branching was later confirmed. In patients 2 and 3, pulmonary artery slings could not be detected clearly by imaging studies before PFB was performed. PFB was arranged again postoperatively for these 2 patients, because of difficulty weaning patient 2 from ventilator support and persistent respiratory distress in patient 3. In conclusion, we expect that more vascular rings will be diagnosed using PFB. This instrument is also useful in making a decision for surgery, and for detecting associated tracheobronchial anomalies preoperatively, assuring appropriate correction intraoperatively, and monitoring the condition of vascular rings postoperatively.

MRI in recurrent nasopharyngeal carcinoma

In this study, we retrospectively reviewed the MRI features of recurrent nasopharyngeal carcinoma (NPC) in 72 patients who underwent MRI before and after gadolinium injection. Recurrent NPC exhibited a high degree of regional spread and a variety of signal intensities and contours. MRI showed a nasopharyngeal mass in 50 patients (69.4 %); other sites of involvement included the parapharyngeal space (44.4 %), nasal cavity (12.5 %), paranasal sinuses (27.8 %), oropharynx (4.2 %), orbit (8.3 %), infratemporal fossa (18.1 %), skull base (59.8 %), intracranial area (51.4 %) and regional lymph nodes (15.3 %). On T2-weighted images, the nasopharyngeal mass gave high signal in 9 of 50 cases (18 %), intermediate in 27 (54 %), mixed in 8 (16 %) and low signal in 6 (12 %). Contrast enhancement was strong in 12 cases (24 %), moderate in 29 (58 %) and heterogeneous in 9 (18 %). The lesion was convex in 31 cases (62 %) and concave or straight in 19 (38 %). Recognition of the distribution and the appearance of recurrent NPC on MRI is essential for timely diagnosis and appropriate treatment.

Magnetic resonance imaging of nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC) is a malignant tumor that shows distinct distributions into geographical and into well-defined high-risk ethnic groups. Radiation therapy is the mainstay of treatment, and imaging plays a central role in tumor mapping and post-treatment follow-up. Magnetic resonance imaging is better than computed tomography in demonstrating tumor extent, tumor recurrence, and postradiation complications. However, differentiating postradiation changes from tumor recurrence may be difficult using magnetic resonance imaging. Mucosal recurrence is best detected with endoscopy.

MRI of thoracic vascular lesions with emphasis on two-dimensional time-of-flight MR angiography

MRI is a valuable method for evaluating thoracic vascular lesions by virtue of its non-invasiveness and multiplanar capability. In addition, ionizing radiation and iodinated contrast medium are not required. Electrocardiographically gated T1 weighted spin echo MRI remains the principal technique for demonstrating the anatomy and morphology of thoracic vascular diseases. Cine MRI allows dynamic evaluation of vascular flow, whereas MR angiography is particularly useful in the two-dimensional (2D) or three-dimensional (3D) display of vascular anatomy. This pictorial review illustrates the use of 2D time-of-flight MR angiography in the assessment of various thoracic vascular conditions including aortic arch and great vessel anomalies, heterotaxic syndromes, aortic dissection, aortic or arch vessel aneurysms, pulmonary embolism, pulmonary sequestration, axillofemoral bypass and tumour/vessel relationships.

Adult ovarian granulosa cell tumors: spectrum of sonographic and CT findings with pathologic correlation

OBJECTIVE

The objective of this study was to evaluate the spectrum of sonographic and CT findings in adult ovarian granulosa cell tumors with pathologic correlation.

MATERIALS AND METHODS

Transabdominal sonograms and CT scans in 13 patients with pathologically proven adult ovarian granulosa cell tumors were retrospectively reviewed. Morphologic characteristics of the lesions shown on sonography and CT were correlated with the histopathologic findings.

RESULTS

On the basis of sonographic and CT findings, 13 cases of adult ovarian granulosa cell tumor were categorized into five morphologic patterns: multilocular cystic (n = 6), thick-walled unilocular cystic (n = 2), thin-walled unilocular cystic (n = 1), homogeneously solid (n = 2), and heterogeneously solid (n = 2) masses. Histopathologically, the multilocular cystic masses were characterized by a predominately macrofollicular pattern of granulosa cells and multiple cystic spaces with watery fluid or hemorrhage. Unilocular central cystic masses seen on CT correlated pathologically with confluence and expansion of the cystic spaces. Homogeneously solid masses seen on sonography and CT were correlated with evenly distributed trabecular or diffuse patterns in the tumor cells. Intratumoral bleeding, infarcts, fibrous degeneration, and irregularly arranged tumor cells yielded heterogeneously solid tumors.

CONCLUSION

Adult ovarian granulosa cell tumors have a varied histologic appearance and a varied arrangement of tumor cells, both of which can create a spectrum of imaging manifestations. Appreciation of these manifestations is helpful in the diagnosis of this tumor.

MRI features of Balo's concentric sclerosis

We report MRI findings in a 56-year-old woman with Balo's concentric sclerosis (BCS) who initially presented with a progressive hemiparesis. MRI showed two lesions with a concentric pattern in the left frontoparietal region and a laminated, arcuate pattern in the right frontal region. These patterns were best seen in post-contrast images and were consistent with BCS. In addition, there were several small cerebral multiple sclerosis-like plaques. The clinical symptoms improved and the MR findings regressed after corticosteroid therapy. The patient had completely recovered 12 months later, except for mild right hand numbness. MRI showed further regression of the lesions, but the concentric pattern was still present. This case demonstrated that BCS can run a benign prolonged course and may persist for a long time. Concentric or laminated contrast enhancement in the acute phase may suggest that bands of demyelination in BCS occur synchronously rather than successively.

Congenital Ewing's sarcoma of the humerus

We report an extremely rare case of Ewing's sarcoma (ES) of the humerus in a Chinese neonate. Plain radiography and magnetic resonance imaging showed extensive neoplastic involvement of the humeral diaphysis and adjacent soft tissues, confirmed on histology and immunohistochemistry as being due to ES. This is the first report of congenital ES in a long bone. Since ultrasound at 20 weeks gestation showed a normal fetal skeleton, the ES may have begun to develop in the late middle or third trimester.

CT features of calcifications in abdominal malignant fibrous histiocytoma

The purpose of this study was to describe the computed tomographic (CT) features of intralesional calcifications in abdominal malignant fibrous histiocytomas (MFH). Forty-three pathologically proven abdominal MFH with preoperative CT were retrospectively reviewed, of which seven tumors with intralesional calcifications were studied with pathohistologic correlation. All seven calcified abdominal MFH belonged to the storiform-pleomorphic subtype with peripherally located calcifications that appeared as either lumpy (three cases) or ringlike (four cases), which were due to the presence of variable amounts of osseous (six cases) and chondroid metaplasia (two cases). About 16% of abdominal MFH, especially the storiform-pleomorphic subtype, exhibited metaplastic calcifications which were characteristically located at the periphery of the tumor and appeared as either lumpy or ringlike on CT.

Congenital bilateral cystic neuroblastoma with liver metastases and massive intracystic haemorrhage

A case of bilateral cystic neuroblastoma with liver metastases in a newborn is reported. CT showed a 10 cm right suprarenal multicystic mass and numerous hepatic cystic masses with intracystic fluid-fluid levels. Multiple smaller cystic lesions were also present in the left adrenal gland. To our knowledge, the CT findings of neonatal bilateral cystic neuroblastoma with liver metastasis and massive acute intracystic haemorrhage has not been previously documented.

Mediastinal lipoblastoma with intraspinal extension: MRI demonstration

Lipoblastomatous lesions are mesenchymal tumors of embryonal white fat and are classified into two forms: a superficial, well-defined mass (lipoblastoma) or a deep, infiltrative lesion (lipoblastomatosis). We report an unique case of mediastinal lipoblastoma in a 17-month-old boy which harbored a dual nature and exhibited the characteristics of both forms, a large well-encapsulated intrathoracic main tumor with focal infiltrative features at the thoracic inlet and transforaminal intraspinal extension forming a long-segment extradural mass. In addition to specific signal characterization of a fatty mediastinal mass with intratumoral streaks and whorls corresponding to the fibrovascular network, magnetic resonance (MR) imaging offered clear demonstration of the chest wall, lower neck and intraspinal extension, which was important for preoperative planning.

Primary synovial sarcoma of the gastrocolic ligament

A case of primary synovial sarcoma of the gastrocolic ligament is reported in a 37-year-old woman. CT showed an encapsulated intraabdominal cystic tumour with an amorphous solid component. Barium studies showed a mass at the gastrocolic ligament which elevated the gastric antrum and displaced the transverse colon downwards. This is the first report of synovial sarcoma formation in the gastrocolic ligament. This tumour may have originated from pluripotential mesenchyme.

Preoperative embolization of meningiomas: comparison of superselective and subselective techniques

We retrospectively compared the efficacy of preoperative superselective and subselective embolization for intracranial meningiomas. Between January and December 1996, 22 patients (7 men, 15 women, mean age 51 +/- 15.5 yr) underwent superselective embolization with 45 to 150 mm polyvinyl alcohol particles after superselective catheterization of the feeding vessels with a microcatheter system. Another 30 patients (12 men, 18 women, mean age 50 +/- 12.9 yr) underwent subselective embolization between January and December 1995 with 150 to 300 mm Gelfoam particles after catheterization of the terminal external carotid artery just proximal to the orifice of the maxillary artery with a 4- or 5-F angiocatheter. The mean intraoperative blood loss (918 versus 1450 mL, p < 0.05), amount of blood transfused (4.9 versus 7.5 units, p = 0.09), and surgical resection time (422 versus 529 min, p < 0.05) were all lower in the superselective group than in the subselective group, while the occurrence of fresh ischemic necrosis (59% versus 53%, p = 0.68), hemorrhage (77% versus 60%, p = 0.19), and embolic material (55% versus 13%, p < 0.05) on pathologic examination were higher in the superselective group. No procedure-related complications occurred in the superselective group, whereas two patients in the subselective group had postoperative scalp necrosis. Our findings show that superselective embolization is more effective than subselective embolization for preoperative endovascular devascularization of meningiomas, with significant reductions in intraoperative blood loss and surgery time. Preoperative embolization of meningiomas, if indicated, should be done with the superselective technique whenever feasible.

Megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS): a case report

Megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS) is a rare congenital disorder characterized by a massively enlarged urinary bladder without mechanical outlet obstruction and microcolon, as well as a hypoperistaltic bowel with normal ganglion cell distribution. We report one such case to discuss the findings of antenatal ultrasound and the radiologic and pathologic features of this condition.

Renal squamous cell carcinoma: CT findings and clinical significance

BACKGROUND

To study the biological behavior of renal squamous cell carcinoma (RSCC).

METHODS

Fifteen cases of RSCC were retrospectively studied. These cases were classified as central (eight cases) and peripheral (seven cases) types by the tumor location. The clinical data and computed tomographic findings were analyzed and compared.

RESULTS

High incidence (87%) of urolithiasis was observed. The prognosis of RSCC was very poor, with a median survival time of 3.5 months. The infectious symptoms, central location, and modified stage IV of the tumor were the poor prognostic factors of RSCC. Two types of RSCC were different in the presenting symptoms, lymph node metastasis, modified tumor staging, and survival time.

CONCLUSION

The central and peripheral types of RSCC were different biologically. High index of suspicion should be maintained when identifying the subtle clues of malignancy in patients with urolithiasis.

MRI of nasopharyngeal carcinoma with emphasis on relationship to radiotherapy

MRI has been used increasingly in the evaluation of nasopharyngeal carcinoma (NPC) because of its good tissue contrast and multiplanar capacity. Although there are some controversies in assessing skull base invasion and cervical metastatic adenopathy, recent reports demonstrate that MRI is currently better than or as good as CT in defining the extent of NPC. During follow-up of patients with NPC after radiotherapy, MRI is also more effective than CT in demonstrating tumor recurrence and in detecting postradiation complications. However, the difficulty of using MRI to detect early mucosal recurrence and to differentiate postradiation tissue changes from local tumor recurrence should be recognized. This paper reviews the literature regarding MRI of NPC related to radiotherapy, with special emphasis on treatment planning, recurrence assessment, and complication detection.

Cervical ecchordosis physaliphora: CT and MR features

We report a case of cervical ecchordosis physaliphora in an elderly man who presented with hemihypoaesthesia and contralateral hemiparesis. MRI showed a well defined, non-enhancing extradural mass lesion on the dorsal surface of the odontoid process of the axis. The lesion was of intermediate signal intensity on T1 weighted images and of low signal intensity on T2 weighted images. CT showed a small bony defect on the adjacent cortex of the odontoid process. Recognition of the imaging features of ecchordosis physaliphora is helpful in suggesting the diagnosis and differentiating the lesion from chordoma.