Correlation between magnetic resonance imaging proton density fat fraction (MRI-PDFF) and liver biopsy to assess hepatic steatosis in obesity

Obesity is highly associated with Non-alcoholic fatty liver disease (NAFLD) and increased risk of liver cirrhosis and liver cancer-related death. We determined the diagnostic performance of the complex-based chemical shift technique MRI-PDFF for quantifying liver fat and its correlation with histopathologic findings in an obese population within 24 h before bariatric surgery. This was a prospective, cross-sectional, Institutional Review Board-approved study of PDFF-MRI of the liver and MRI-DIXON image volume before bariatric surgery. Liver tissues were obtained during bariatric surgery. The prevalence of NAFLD in the investigated cohort was as high as 94%. Histologic hepatic steatosis grades 0, 1, 2, and 3 were observed in 3 (6%), 25 (50%), 14 (28%), and 8 (16%) of 50 obese patients, respectively. The mean percentages of MRI-PDFF from the anterior and posterior right hepatic lobe and left lobe vs. isolate left hepatic lobe were 15.6% (standard deviation [SD], 9.28%) vs. 16.29% (SD, 9.25%). There was a strong correlation between the percentage of steatotic hepatocytes and MRI-PDFF in the left hepatic lobe (r = 0.82, p < 0.001) and the mean value (r = 0.78, p < 0.001). There was a strong correlation between MRI-derived subcutaneous adipose tissue volume and total body fat mass by dual-energy X-ray absorptiometry, especially at the L2-3 and L4 level (r = 0.85, p < 0.001). MRI-PDFF showed good performance in assessing hepatic steatosis and was an excellent noninvasive technique for monitoring hepatic steatosis in an obese population.

Residual renal volume as a long-term independent predictive factor of developing chronic kidney disease after donor nephrectomy

To assess the long-term association between the residual renal volume and the progression of chronic kidney disease (CKD) in kidney donors following open or laparoscopic donor nephrectomy. A retrospective observational study involving 452 individuals who underwent open or laparoscopic donor nephrectomy at Ramathibodi Hospital, Bangkok, Thailand. The study spanned over a comprehensive 60-month monitoring period. Residual renal volume was determined through Computer Tomography. Patient characteristics, surgical techniques, donated kidney side, and estimated glomerular filtration rate (eGFR) were collected and analysed. In a multivariate analysis, a residual renal volume exceeding 50% of original volume is associated with an increased likelihood of developing CKD, with a hazard ratio (HR) of 1.675 (P < 0.05), and male gender has a hazard ratio (HR) of 4.013 (P < 0.001). Additionally, age is identified as a minor risk factor for developing CKD, with hazard ratio (HR) of 1.107 (P < 0.001). Higher residual renal volume, male gender, and older age were identified as independent risk factors for the development of CKD following open or laparoscopic donor nephrectomy during long-term follow-up.

Optimizing the Yield of Abnormal Preoperative Chest Radiographs in Elective Non-cardiothoracic Surgery: Development of a Risk Prediction Score and External Validation

BACKGROUND

Guideline recommendations for preoperative chest radiographs vary to the extent that individual patient benefit is unclear. We developed and validated a prediction score for abnormal preoperative chest radiographs in adult patients undergoing elective non-cardiothoracic surgery.

METHODS

Our prospective observational study recruited 703 adult patients who underwent elective non-cardiothoracic surgery at Ramathibodi Hospital. We developed a risk prediction score for abnormal preoperative chest radiographs with external validation using data from 411 patients recruited from Thammasat University Hospital. The discriminative performance was assessed by receiver operating curve analysis. In addition, we assessed the contribution of abnormal chest radiographs to perioperative management.

RESULTS

Abnormal preoperative chest radiographs were found in 19.5% of the 703 patients. Age, pulmonary disease, cardiac disease, and diabetes were significant factors. The model showed good performance with a C-statistics of 0.739 (95% CI, 0.691-0.786). We classified patients into four groups based on risk scores. The posttest probabilities in the intermediate-, intermediate-high-, and high-risk groups were 33.2%, 59.8%, and 75.7%, respectively. The model fitted well with the external validation data with a C statistic of 0.731 (95% CI, 0.674-0.789). One (0.4%) abnormal chest radiograph from the low-risk group and three (2.4%) abnormal chest radiographs from the intermediate-to-high-risk group had a major impact on perioperative management.

CONCLUSIONS

Four predictors including age, pulmonary disease, cardiac disease, and diabetes were associated with abnormal preoperative chest radiographs. Our risk score demonstrated good performance and may help identify patients at higher risk of chest abnormalities.

Propensity Score Matched Study of Tri-Weekly vs. Weekly Platinum-Based Chemotherapy Concurrent with Radiotherapy in the Treatment of Locally Advanced Cervical Cancer

Objective: To compare tumor control and toxicity between tri-weekly chemotherapy and weekly platinum-based chemotherapy in locally advanced cervical cancer using the propensity score matching method.Material and Methods: DESIGN: Retrospective cohort with propensity score matched population. SETTING: Four university hospitals. PARTICIPANTS: 781 advanced local cervical cancer patients. INTERVENTION: tri-weekly platinum-based chemoradiotherapy versus weekly chemoradiotherapy OUTCOMES: Overall survival (OS), local recurrence-free survival (LRFS), regional recurrence-free survival (RRFS), distant metastasis-free survival (DMFS), and toxicity, including hematological and renal toxicity.Results: Overall median follow-up time was 59.5 months. After the propensity score matching process was completed, 326 patients were analyzed (163 in each group). The five-year OS was 66% and 64% (p 0.630); five-year LRFS was 85% and 81% (p 0.209); five-year RRFS was 89% and 94% (p 0.307); and five-year DMFS was 75% and 79% (p 0.420) in the tri-weekly and weekly groups, respectively. The patients in the tri-weekly and the weekly group had grade 2-3 neutropenia (10.5% vs 2.5%). The other toxicities appeared to be similar in both groups in terms of white blood count, platelet and creatinine.Conclusion: There was a potential small benefit of local control (4%) and overall survival (2%) with the tri-weekly regimen but we could not demonstrate statistical significance. However, this came at the price of an increase of 7% to 8% in grade 2-3 neutropenia.

Using iron sucrose-labeled adipose-derived mesenchymal stem cells in 1.5 and 3 T MRI tracking: An in vitro study

Objectives

The objective of this study was to investigate iron sucrose labeling in mesenchymal stem cell (MSCs) tracking.

Background

Adipose-derived mesenchymal stem cell-based therapy is a promising strategy for promoting musculoskeletal repair.

Methods

Iron sucrose-labeled adipose-derived mesenchymal stem cells (IS-labeled ASCs) were tracked using T2-and T2∗-weighted sequences by 1.5 and 3 T MRI in an in vitro model. ASCs were isolated from cosmetic liposuction specimens. ASCs from passages 4-6 were labeled with iron sucrose (Venofer®) which was added to the cell culture medium. Pre- and post-iron sucrose labeled ASCs were evaluated for cell surface immunophenotypes. Cell viability as well as chondrogenic, adipogenic and osteogenic differentiation of IS-labeled-ASCs were evaluated. The IS-labeled ASCs were titrated into microtubes at 1 × 10³, 1 × 10⁴, 1 × 10⁵ and 1 × 10⁶ cells/ml/microtube and their intensities were determined by 1.5 and 3T MRI using T2-and T2∗-weighted sequences.

Results

The expression markers of IS-labeled ASCs from flow cytometry were equivalent to control. The mean cell viability was 97.73 ± 2.06%. Cell differentiations of IS-labeled ASCs were confirmed in each lineage using specific staining solutions. T2∗-weighted sequences (T2∗) were able to detect iron sucrose labeled-ASCs at a minimum of 1 × 10⁵ cells/ml/microtube using 1.5 and 3T MRI, but the detection sensitivity was lower with T2-weighted sequences (T2).

Conclusions

Iron sucrose incubation is a safe alternative method for ASCs labeling and tracking using MRI following treatment. Clinicians and researchers should be able to visualize the location of ASCs engraftment without secondary surgical investigation involving tissue sampling.

The association between the outcomes of extraperitoneal laparoscopic radical prostatectomy and the anthropometric measurements of the prostate by magnetic resonance imaging

Introduction and objective

To determine the association between the anthropometric measurements by magnetic resonance imaging (MRI) and perioperative outcomes of extraperitoneal laparoscopic radical prostatectomy (ELRP).

Materials and Methods

From 2008 to June 2016, 86 patients underwent preoperative MRI prior to undergoing ELRP for localized prostate cancer. We analyzed the associations between anthropometric measurements of MRI and the perioperative outcomes of patients who underwent ELRP.

Results

The mean patient age was 69.61±8.30 years. The medians of operating time and blood loss were 2.30 hours and 725.30ml, respectively. The total post-surgical complication rate was 1.16%. The median hospital stay was 6.50 days. The pathological stages for T2 and T3 were 45.74% and 34.04%, respectively. The rate as positive surgical margins (PSMs) was 18.09% (pT2 and pT3; 6.38% and 9.57%). The angles between pubic bone and prostate gland (angle 1&2), were significantly associated with operative time and hospital stay, respectively (p<0.05). There was no correlation between the pelvimetry and positive surgical margin.

Conclusions

The findings of the present study suggest that anthropometric measurements of the MRI are related to operative difficulties in ELRP. This study confirmed that MRI planning is the key to preventing complications in ELRP.

Sister Mary Joseph nodule caused by metastatic desmoplastic small round cell tumor: A clinicopathological report

Sister Mary Joseph nodule is an uncommon metastatic intra-abdominal malignancy involving the umbilicus. The present study describes a rare case of desmoplastic small round cell tumor (DSRCT), histological grade 3, high grade, Gilly classification 4, stage IV, in an 18-year-old Thai man presenting with the Sister Mary Joseph nodule, ascites and pleural effusion. The histopathological examination of the umbilical mass revealed the presence of malignant small round cells associated with prominent stromal desmoplasia. Immunohistochemical stains showed positive reactivity to cytokeratin, desmin, neuron-specific enolase, Wilms' tumor 1, CD56, CD99 and SWI/SNF-related matrix-associated actin-dependent regulator of chromatin subfamily B member 1 (SMARCB1)/INI1 in the small round cells. Fine needle aspirations of the ascitic fluid and pleural effusion were performed, and immunocytochemistry revealed a metastatic DSRCT. The patient received a VDC/IE regimen of chemotherapy, comprising vincristine, doxorubicin, and cyclophosphamide alternating with ifosfamide and etoposide; however, the patient developed systemic metastasis and succumbed to the disease 6 months later.

Health economic evaluation of Gd-EOB-DTPA MRI vs ECCM-MRI and multi-detector computed tomography in patients with suspected hepatocellular carcinoma in Thailand and South Korea

OBJECTIVE

The effectiveness of treatment decisions and economic outcomes of using gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (Gd-EOB-DTPA-MRI) were compared with extracellular contrast media-enhanced MRI (ECCM-MRI) and multi-detector computed tomography (MDCT) as initial procedures in patients with suspected hepatocellular carcinoma (HCC) in South Korea and Thailand.

METHODS

A decision-tree model simulated the clinical pathway for patients with suspected HCC from the first imaging procedure to a confirmed treatment decision. Input data (probabilities and resource consumptions) were estimated and validated by clinical experts. Costs for diagnostic alternatives and related treatment options were derived from published sources, taking into account both payer's and hospital's perspectives.

RESULTS

All experts from Korea and Thailand agreed that Gd-EOB-DTPA-MRI yields the highest diagnostic certainty and minimizes the need for additional confirmatory diagnostic procedures in HCC. In Korea, from the payer's perspective, total cost was USD $3087/patient to reach a confirmed treatment decision using Gd-EOB-DTPA-MRI (vs $3205/patient for MDCT and $3403/patient for ECCM-MRI). From the hospital's perspective, Gd-EOB-DTPA-MRI incurred the lowest cost ($2289/patient vs $2320/patient and $2528/patient, respectively). In Thailand, Gd-EOB-DTPA-MRI was the least costly alternative for the payer ($702/patient vs $931/patient for MDCT and $873/patient for ECCM-MRI). From the hospital's perspective, costs were $1106/patient, $1178/patient, and $1087/patient for Gd-EOB-DTPA-MRI, MDCT, and ECCM-MRI, respectively.

CONCLUSIONS

Gd-EOB-DTPA-MRI as an initial imaging procedure in patients with suspected HCC provides better diagnostic certainty and relevant statutory health insurance cost savings in Thailand and Korea, compared with ECCM-MRI and MDCT.

DCE-MRI-Derived Parameters as Predictors of Response to Neo-Adjuvant Chemoradiation Treatment of Rectal Carcinoma

BACKGROUND

Preoperative combined chemoradiation treatment (CRT) is now accepted as the treatment of choice due to its benefits of decreasing the primary tumor volume and enhancing the sphincter preservation surgery. Determining whether a patient is responding to therapy is crucial for rectal cancer patients who may benefit from prompt treatment modifications.

OBJECTIVE

To evaluate the use of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in predicting the treatment response.

MATERIAL AND METHOD

Nineteen patients with histologically proven rectal adenocarcinoma who were candidates for neo-adjuvant CRT were prospectively included. All patients were examined by conventional and DCE-MRi at three time points (pre-, during-, and post-CRT). Surgical resection was performed after complete CRT. The pathological response and Dworak regression grade were assessed. All parameters were blindly analyzed.

RESULTS

The median pathologic response rate for all patients was 40%. Dworak regression grades of 0, 1, 2, 3, and 4 were found in 0.0%, 21.1%, 42.1%, 26.3%, and 10.5% of patients, respectively. The tumor thickness and length were 30% and 32.9% lower at during-CRT and 40.6% and 44.7% lower post-CRT and had moderate and fair negative correlations with the pathologic response rate and Dworak regression rate, respectively. Among the DCE-MRI parameters, only a change in the time to peak between pre- and during-CRT was correlated with the Dworak regression grade (p = 0.01). The percentage change in the time to peak in patients with poor regression (grades 0-1) was significantly greater than in patients with intermediate/complete regression (grades 2-4) [139.25% vs. 6.13%].

CONCLUSION

Changes in the tumor thickness and length evaluated by conventional MRI and the time to peak evaluated by DCE-MRI during CRT may be useful for predicting the treatment response of rectal cancer patients.

Satisfaction of imaging report rendered in emergency setting: a survey of radiology and referring physicians

RATIONALE AND OBJECTIVES

To determine physicians' preference toward three types of structured imaging reports (basic structured report [BSR], itemized report [IR], and point-and-click report [PCR]) used in emergency radiology.

MATERIALS AND METHODS

Survey questions were created and considered valid and reliable based on index of item objective congruence from three specialists (>0.75) and a pilot of 25 subjects (Cronbach alpha, 0.83-1.00). Respondents included trainees and attendings in radiology and referring physicians working in the academic emergency department at the time of survey rollout. They were provided report examples of each type and asked to complete a questionnaire consisting of the following five parts: demographics, necessity of imaging report, report quality (content, format and organization, and language), process of reporting, and components of imaging report. For rating scores, the higher value means the higher preference and agreement.

RESULTS

The survey received 79.5% response rate. Respondents included 101 physicians (mean age, 29.4 years; 61 radiology physicians and 40 referring physicians; 81 trainees and 20 attending). Overall, IR was preferred over PCR and BSR by all physicians with scores (out of 10) as follows: IR, 7.62-8.83; PCR, 6.62-8.55; BSR, 5.23-6.65; P < .001. IR received scores (out of 5) of 4.03-4.37, PCR 3.32-4.52, and BSR 2.59-3.86 for report quality. For process of reporting, IR had scores (out of 5) of 3.80-4.56, PCR 2.79-4.09, and BSR 2.32-3.56.

CONCLUSIONS

In emergency setting, physicians preferred IR over PCR and BSR. IR and PCR were equal in report quality metrics, but IR was most preferred in the process of reporting. BSR ranked last in both quality and process.

Ultrasound surveillance for hepatocellular carcinoma of at-risk patients in Ramathibodi Hospital

BACKGROUND

Surveillance for hepatocellular carcinoma (HCC) is recommended for patients at risk of developing HCC. However the pattern of surveillance in clinical practice is unclear.

OBJECTIVE

To assess the adherence of surveillance program in the detection of HCC and to determine the prevalence of HCC in the at-risk patients who were on surveillance in Ramathibodi Hospital.

MATERIAL AND METHOD

Retrospective descriptive study of at-risk patients, who were followed in the liver clinic at Ramathibodi Hospital between January 1, 2007 and December 31, 2012. Clinical data were collected from electronic medical records and radiologic data were extractedfrom the radiology database (PACS). The US findings of focal liver lesion were analyzed for number size, location, and echogenicity. When focal liver lesions suggestive of HCC were detected on ultrasonography, dynamic contrast enhanced CT or AMRI was used to diagnose HCC. On CT/MRI, focal lesions were considered to be HCC when hypervascularity in the arterial phase and washout in the portal venous or delayed phase was found

RESULTS

Nine hundred seven patients with risk(s) for HCC underwent ultrasound surveillance. The mean number of ultrasound examinations per patient was 4.7±2.2 scans during the course offollow-up. The mean total adherence time was 37.0±17.1 months. The median time interval between each ultrasound examination was 8.4 months (range: 1.1-63.0 months). Focal liver lesions were detected in 161 of 907patients (17.8%). No new focal liver lesion was detected at less than 3-month interval. The majority of patients were evaluatedfurther by MRI (n = 99; 62.3%) or by CT scan (n = 33; 20.8%). Theperiod prevalence of HCC in patients who received US surveillance was 3.5% (32 patients in 907patients). Most ofpatients with HCC were male (71.9%) and the major risk factor was chronic hepatitis B (50.0%). Twenty-one of 32 patients (65.6%) had normal serum AFP levels. Most HCC's (75.0%) were detected at 8-month interval. The cumulative percentage of HCC's detected at 6-month and 12-month surveillance intervals were 11.1% and 70.4%, respectively. The median tumor size was 22.5 mm, ranging from 12-134 mm. At the time ofHCC diagnosis, eight patients (25.0%) had HCC within BCLC very early stage (by size criteria) and 19 patients (59.4%) were in BCLC early stage.

CONCLUSION

Although there were irregular surveillance intervals in our clinical practice, the overall adherence ofpatients to surveillance was acceptable, with the period prevalence of HCC 3.5% and the majority discovered in the early stage.

Added value of hepatobiliary phase gadoxetic acid-enhanced MRI for diagnosing hepatocellular carcinoma in high-risk patients

AIM: To determine the added value of hepatobiliary phase (HBP) gadoxetic acid-enhanced magnetic resonance imaging (MRI) in evaluating hepatic nodules in high-risk patients.

METHODS: The institutional review board approved this retrospective study and waived the requirement for informed consent. This study included 100 patients at high risk for hepatocellular carcinoma (HCC) and 105 hepatic nodules that were larger than 1 cm. A blind review of two MR image sets was performed in a random order: set 1, unenhanced (T1- and T2-weighted) and dynamic images; and set 2, unenhanced, dynamic 20-min and HBP images. The diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were compared for the two image sets. Univariate and multivariate analyses were performed on the MR characteristics utilized to diagnose HCC.

RESULTS: A total of 105 hepatic nodules were identified in 100 patients. Fifty-nine nodules were confirmed to be HCC. The diameter of the 59 HCCs ranged from 1 to 12 cm (mean: 1.9 cm). The remaining 46 nodules were benign (28 were of hepatocyte origin, nine were hepatic cysts, seven were hemangiomas, one was chronic inflammation, and one was focal fat infiltration). The diagnostic accuracy significantly increased with the addition of HBP images, from 88.7% in set 1 to 95.5% in set 2 (P = 0.002). In set 1 vs set 2, the sensitivity and NPV increased from 79.7% to 93.2% and from 78.9% to 91.8%, respectively, whereas the specificity and PPV were not significantly different. The hypointensity on the HBP images was the most sensitive (93.2%), and typical arterial enhancement followed by washout was the most specific (97.8%). The multivariate analysis revealed that typical arterial enhancement followed by washout, hyperintensity on T2-weighted images, and hypointensity on HBP images were statistically significant MRI findings that could diagnose HCC (P < 0.05).

CONCLUSION: The addition of HBP gadoxetic acid-enhanced MRI statistically improved the diagnostic accuracy in HCCs larger than 1 cm. Typical arterial enhancement followed by washout and hypointensity on HBP images are useful for diagnosing HCC.

Clinical applications of diffusion-weighted-MRI in prostate cancer

OBJECTIVE

To determine the relationship between the apparent diffusion coefficient (ADC) values calculated from diffusion-weighted (DW) MR imaging in different b values and tumor grading by Gleason scores of the peripheral zone prostate cancer

MATERIAL AND METHOD

Thirty-nine patients with prostate cancer who underwent pre-operative endorectal Diffusion-Weighted (DW) magnetic resonance (AIR) imaging between March 2006 and March 2010 were included. Regions of interest (ROIs) were drawn on ADC maps at sites of visible tumor on DW images and ADC maps comparison to histopathology. Differentiation between ADC values of tumor and non-tumor areas were analyzed by using paired t-test and sign-test and between tumors grading were analyzed by using Wilcoxon rank-sum (Mann-Whitney) test and Kruskal-Wallis equality-of population rank test.

RESULTS

The mean ADC of tumor is lower than non-tumor areas at all b-values. There is negative correlation between ADC value and tumor grading with statistical significance at b = 1,000 sec/mm2, between tumor grade I (1.95 x 10(-3) mm2/sec, SD = 0.33) and tumor grade II (1.16 x 10(-3) mm2/sec, SD = 0.27) (p = 0.03) and between tumor grade I and tumor grade III (1.10 x 10(-3) mm2/sec, SD = 0.36) (p = 0.002) and at b = 2,000 sec/mm2, between tumor grade I (2.21 x 10(-3) mm2/sec, SD = 0.08) and tumor grade II (1.22 x 10(-3) mm2/sec, SD = 0.38) (p = 0.01), and between tumor grade I and tumor grade III (1.32 x 10(-3) mm2/sec, SD = 0.49) (p = 0.04). There is no statistical significance difference between tumor grade II and grade III.

CONCLUSION

Tumor shows restricted diffusion with ADC value lower than non-tumor areas. There is a significant negative correlation between ADCs and tumor grading between low and intermediate grades and between low and high grades tumor at the b = 1,000 and 2, 000 sec/mm2. ADC maps may be a useful tool for non-invasive assessment of the aggressiveness of prostate cancers that are visible on MR images.

Fungal appendicitis: a case series and review of the literature

Appendicitis is a condition characterized by inflammation of the vermiform appendix, which is commonly caused by bacterial infections and rarely caused by fungal organisms. In the present study, we reviewed the prevalence, clinicopathological features, and therapeutic management of fungal appendicitis. During July 2010 to June 2011, the pathology of 262 resected vermiform appendices was reviewed. Fungal appendicitis occurred in 1.15%, including two cases of Candida spp and one case of Aspergillus spp infection. All patients were immunocompromised and presented with the classical signs and symptoms of appendicitis with the onset of illness less than two days. They were considered for acute appendicitis and underwent appendectomy. The histopathology of the resected vermiform appendix showed fungal organisms with suppurative inflammation and secondary periappendiceal peritonitis. The curative treatment was presented in 1-out-of-3 cases. One patient was alive during a follow-up of eight months. Two patients died, and an autopsy was performed in one case. Although fungal appendicitis was uncommon, the disease might occur among immunosuppressed patients who have developed classical signs and symptoms of appendicitis. Early diagnosis and prompt surgery with medical treatment are associated with a survival advantage.

The influence of MR imaging on changes in patient counseling in obstetric patients with suspected fetal anomalies by ultrasound

OBJECTIVE

To determine the frequency of additional information provided by magnetic resonance (MR) imaging in supplement to ultrasound (US) in patients with fetal anomaly and to determine the influence of MR imaging findings on patient counseling.

MATERIAL AND METHOD

MR imaging offetus was performed in 26 patients who have abnormal ultrasound results. Referring obstetricians were asked about how the additional information provided by MR imaging have effect on their decision marking, patient counseling, and case management.

RESULTS

MR imaging in 23 of 26 fetuses was technically successful. MR imaging provided additional information in 14/23 (60.9%) cases. In the other nine (39.1%) cases, MR imaging confirmed US diagnosis but did not give supplementary information. Additional information from MR imaging affected patient counseling in five (21.7%) cases and did not affect patient counseling in the other nine (39.1%) cases. In 14 cases with additional information from MR imaging, there were isolated CNS involvement in five (35.7%) cases, isolated extra-CNS involvement in two (14.3%) cases, multisystem involvement in five (35.7%) cases, and other-category in two (14.3%) case.

CONCLUSION

MR imaging can provide additional information that have influence on patient counseling and patient care, particularly in cases with CNS and multisystem anomaly.

Transrectal ultrasound (TRUS) findings of the prostate gland in late onset hypogonadism with testosterone supplementation in correlation with clinical outcome

OBJECTIVE

To determine the TRUS findings of the prostate and correlation of ultrasoundfindings with clinical outcomes in late-onset hypogonadal (LOH) men with testosterone supplementation.

MATERIAL AND METHOD

Between January 2007 and September 2010, TRUS findings and clinical outcomes of 16 from 226 subjects were studied The demographic data, ultrasound parameters as prostate volume and vascularity, and clinical parameters were evaluated Correlation between ultrasound and clinical parameters were analyzed using Pearson correlation analysis.

RESULTS

During mean time follow-up of 6.48 months, the volume of the central gland (CG) significantly increased (p = 0.02), the volume of the total gland (TG) increased, and the volume of the peripheral zone (PZ) slightly decreased. The vascularity of the TG, CG, and PZ were significantly increased. The periurethral region vascularity was not significantly increased (p = 0.06), whereas total serum testosterone, prostate specific antigen (PSA), and PSA density were increased The International Prostate Symptom Score (IPSS) was significantly decreased (p < 0.001). There was a significant correlation between increased prostate volume and increased serum PSA.

CONCLUSION

Testosterone supplementation in LOH men was found to cause an increase in TG volume during the first six months. The preferentially increased CG volume and prostatic vascularity might be due to exogenous testosterone. The authors observed a significantly increased PSA with a strong correlation between serum PSA and prostate volume.

Adrenal histoplasmosis: a case series and review of the literature

Adrenal histoplasmosis is an uncommon mycotic disease typically caused by Histoplasma capsulatum. The objective was to determine the clinicopathological findings in adrenal histoplasmosis. Pathological records were searched from the database at the Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University from 1993 to 2008 for cases of adrenal histoplasmosis. The keywords were "histoplasmosis" and "adrenal gland". Adrenal histoplasmosis was diagnosed by histopathology and Gomori-Grocott methenamine silver staining. Histoplasma capsulatum was confirmed by tissue culture and/or serology. The authors report seven cases of adrenal histoplasmosis in immunocompetent patients. The mean age at diagnosis was 67 years. All patients presented as chronic fatigue syndrome. The onset of symptoms ranged from one to three months. Addison's disease was found in adrenal histoplasmosis in one case (14.3%). The computed tomography revealed adrenal nodules measuring 1.2 to 7.8 cm in diameter. The histopathology showed granulomatous inflammation with caseous necrosis. Culture of adrenal tissue from two patients revealed Histoplasma capsulatum. Serum Histoplasma antibodies were positive in four cases. A cure was accomplished in 6 out of 7 cases (85.7%). The patients were followed up for 2.5 to 16.5 years.

Eosinophilic appendicitis caused by Schistosoma japonicum: a case report and review of the literature

Parasitic appendicitis is uncommon. The authors reviewed the pathology of 4,130 appendices resected over the past 10 years (2000 to 2009). Only one case of eosinophilic appendicitis caused by Schistosoma japonicum was identified. The overall prevalence of schistosomal appendicitis was 0.024%. The case was a 61-year-old woman who presented with right lower quadrant abdominal pain. She had been a farmer in Chumphon and Surat Thani Provinces, which are endemic for schistosomiasis in Thailand. Physical, laboratory and ultrasound examinations were suggestive of acute appendicitis. She underwent emergency appendectomy. Intraoperative findings revealed a ruptured appendix with a fecalith in the appendiceal lumen. The histopathologic diagnosis was suppurative eosinophilic appendicitis with schistosomal ova in the mucosa, submucosa, muscular layer and vascular lumens, identified as S. japonicum eggs. The patient was treated for the parasite with praziquantal. We briefly review the clinicopathologic features and pathogenesis of schistosomal appendicitis.

Supplement value of magnetic resonance imaging in small hepatic lesion (< or = 20 mm) detected on routine computed tomography

OBJECTIVE

To determine the supplemental MRI value in characterization of small hepatic lesions (< or = 20 mm) indetermined by routine CT scan.

MATERIAL AND METHOD

This was a retrospective study. Sixty-four patients with 81 indeterminate small hepatic lesions on the CT scan were included in this study. Two radiologists simultaneously evaluated the CT scan, followed by MRI. Patient history, imaging record, and final diagnosis were blinded. Final diagnoses were made by interpretation of all medical data and defined these lesions as benign or malignancy by using either histology or follow-up imaging combined with laboratory data.

RESULTS

In 64 patients, 62 lesions (76.5%) of 81 indeterminate lesions were benign, whereas 19 lesions (23.5%) were malignant. MRI interpreted 55 lesions as benign, 17 lesions as malignant, and 9 as indeterminate lesions. If the indeterminate lesions were assumed as benign lesions, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), are 68.4%, 93.6%, 76.5%, and 90.6%, respectively.

CONCLUSION

MRI can supplement CT scan in characterization of small hepatic lesion with high specificity and accuracy.

Inflammatory myofibroblastic tumor ofabdomen: computerized tomographic (CT) and pathological findings

Inflammatory Myofibroblastic Tumor (IMT) is the recent name of Inflammatory pseudotumor which was in intermediate group of fibrous-origin tumor. The authors retrospectively reviewed such cases in Ramathibodi Hospital from January 2001 to December 2005. There were 115 cases of fibrous-origin tumor which was IMT in 17 cases. Nine cases occurred in the abdomen and only 3 of these had complete computerized tomographic (CT) imaging. One was hypodense liver mass with thick rim enhancement. Another one in the liver presented as a liver abscess which appeared as multiloculated hypodense mass with enhanced septum. The third case was a large malignant-looking retroperitoneal mass and having a small accompanying hepatic lesion which rapidly grew in the follow up study at nine months. IMT in the abdomen was scanty. The diagnosis was done with difficulty because of different signs and symptoms such as fever and palpable abdominal mass. The laboratory findings were nonspecific or within normal limits. Tissue biopsy was the way of definite diagnosis. We reported 3 cases of abdominal IMT with variable imaging findings that may lead to inappropriate treatment. Recognization of such findings will help achieve correct diagnosis.

Hepatic fat content is a determinant of postprandial triglyceride levels in type 2 diabetes mellitus patients with normal fasting triglyceride

Postprandial hypertriglyceridemia is common in type 2 diabetes mellitus (T2D). Significant numbers of T2D patients who have normal fasting triglyceride (TG) have postprandial hypertriglyceridemia. The role of regional adipose tissue and adiponectin on postprandial TG responses in this group of T2D patients is unclear. This study aimed to examine the contribution of regional adipose tissue and adiponectin to the variation of postprandial TG responses in T2D patients who have normal fasting TG levels. Thirty-one Thai T2D patients who had fasting TG<1.7 mmol/L were studied. All were treated with diet control or sulphonylurea and/or metformin. None was treated with lipid-lowering agents. Mixed-meal test was performed after overnight fast. Plasma glucose, insulin, and TG were measured before and 1, 2, 3, and 4 hours after the test. Adiponectin was measured in fasting state. Visceral as well as superficial and deep subcutaneous abdominal adipose tissues were determined by magnetic resonance imaging, and hepatic fat content (HFC) was determined by magnetic resonance spectroscopy. Univariate and multivariate regression analyses of postprandial TG and regional adipose tissue and metabolic parameters were performed. The TG levels before and 1, 2, 3, and 4 hours after the mixed meal were 1.32+/-0.40 (SD), 1.40+/-0.41, 1.59+/-0.40, 1.77+/-0.57, and 1.80+/-0.66 mmol/L, respectively (P<.0001). The area under the curve (AUC) of postprandial TG was positively and significantly correlated with fasting TG (r=0.84, P<.0001) and log.HFC (r=0.456, P=.033) and was inclined to be correlated with log.deep subcutaneous adipose tissue (r=0.38, P=.05) and sex (r=0.326, P=.073). The AUC of postprandial TG was not correlated with age, body mass index, waist circumference, log.superficial subcutaneous adipose tissue, log.visceral adipose tissue, hemoglobin A1c, fasting glucose, AUC.glucose, log.fasting insulin, log.AUC.insulin, log.homeostasis model assessment%B, log.homeostasis model assessment of insulin resistance, and adiponectin. Only fasting TG (beta=.815, P<.0001) and log.HFC (beta=.249, P=.035) predicted AUC of postprandial TG in regression model (adjusted R2=0.84, P<.0001). In conclusion, in T2D patients with normal fasting TG, the increase of postprandial TG levels is directly determined by fasting TG level and the amount of hepatic fat.

Assessment of gastrointestinal stromal tumors with computed tomography following treatment with imatinib mesylate

AIM: To evaluate and characterize the patterns of disease progression of metastatic or unresectable gastrointestinal stromal tumor (GIST) treated with imatinib mesylate, and to determine the prognostic significance associated with disease progression.

METHODS: Clinical data and computed tomography (CT) images were retrospectively reviewed in 17 GIST patients who were treated with imatinib mesylate from October 2002 to October 2006. Apart from using size measurement for evaluation of tumor response [Response Evaluation Criteria in Solid Tumors (RECIST) criteria], patterns of CT changes during treatment were evaluated and correlated with clinical data.

RESULTS: There were eight non-responders and nine responders. Five patterns of CT change during treatment were found: focal progression (FP), generalized progression (GP), generalized cystic change (GC), new cystic lesion (NC) and new solid lesion (NS). At the end of study, all non-responders showed GP, whereas responders showed cystic change (GC and NC) and response according to RECIST criteria. Overall survival was significantly better in patients with cystic change or response within the RECIST criteria compared with GP patients (P = 0.0271).

CONCLUSION: Various patterns of CT change in patients with GIST who responded to imatinib mesylate were demonstrated, and might determine the prognosis of the disease. A combination of RECIST criteria and pattern of CT change are proposed for response evaluation in GIST.

Abdominal manifestation and complications in systemic lupus erythematosus: emphasis on CT findings

OBJECTIVE

To describe computed tomography (CT) features in SLE patients with suspected abdominal involvement or complications.

MATERIAL AND METHOD

SLE Patients who presented with suspected abdominal involvement or complications and underwent CT between 2001 and 2005 were retrospectively reviewed. All CT studies were performed within 21 days of the onset of symptoms.

RESULTS

Thirty-two SLE patients with 53 CT examinations including imaging findings and clinical data were reviewed. There were 29 cases with abdominal findings related to SLE including gastrointestinal vasculitis (6 cases), acute pancreatitis (8 cases), genitourinary abnormality (13 cases), hepatosplenomegaly, and ascites. Bowel wall thickening with target sign in CT is characteristics of GI vasculitis. Mild pancreatitis by CT scoring index was found in most cases. Five cases had diffuse bladder wall thickening and three cases also had bilateral hydronephrosis and hydroureter. Sixteen cases had other findings not related to SLE including bowel obstruction, splenic infarction, appendicitis, and hematoma.

CONCLUSION

The common CT findings and complications in SLE patients who suspected abdominal involvement were presented CT is useful for detecting the primary cause of abdominal symptoms, planning treatment, and monitoring for complication.

CT Quantification of Effects of Thalidomide in Patients with Metastatic Renal Cell Carcinoma

OBJECTIVE

Our objective was to use functional CT to evaluate the effects of thalidomide in patients with metastatic renal cell carcinoma.

SUBJECTS AND METHODS

Patients with proven metastatic renal cell carcinoma were examined prospectively with functional CT. Functional CT studies (cine mode, 4 x 5 mm) were performed through the tumor after i.v. administration of a bolus of contrast material before and every 12 weeks after treatment with thalidomide. Quantitative values for blood flow, blood volume, mean transit time, and permeability-surface area product were calculated with commercial software. The average difference in percentage change in functional CT parameters from pretreatment to 12 and 24 weeks after treatment and the median difference in percentage change in functional CT parameters between response groups were assessed. We also tested whether percentage changes in functional CT parameters 12 weeks after treatment correlated with time to progression of disease and size of the perfused lesion.

RESULTS

Sixteen patients with a total of 23 tumors underwent at least one follow-up functional CT examination. Blood flow, blood volume, and permeability-surface area product decreased significantly 12 weeks (-18%, p = 0.0039; -15%, p = 0.0350; -24%, p = 0.0010) and 24 weeks (-28%, p = 0.017; -19%, p = 0.0300; -25%, p = 0.0031) after treatment with thalidomide. Time to progression correlated significantly with percentage change in blood flow (r = -0.34; p = 0.040) and permeability-surface area product (r = -0.36, p = 0.023) at 12 weeks. Responders had a significantly larger decrease in blood flow 12 weeks after treatment than did nonresponders (-29% vs -6%; p = 0.032). We also found a significant correlation between decrease in size of the perfused lesion and percentage decrease in blood flow 12 weeks after treatment (r = 0.50; p = 0.019).

CONCLUSION

Changes in functional CT parameters 12 weeks after treatment may be useful for monitoring the effects of thalidomide and predicting treatment outcome among patients with metastatic renal cell carcinoma. Further study with a larger clinical trial is needed.

Diagnostic accuracy of MRI/MRSI for patients with persistently high PSA levels and negative TRUS-guided biopsy results

OBJECTIVE

To prospectively evaluate the accuracy of transrectal ultrasonographic (TRUS)-guided biopsies by using combined magnetic resonance imaging (MRI) and magnetic resonance spectroscopic imaging (MRSI) in patients with persistently high prostate-specific antigen (PSA) levels and negative TRUS-guided biopsy results.

MATERIAL AND METHOD

Twenty-one patients (age range 50-77 years, average 61.4 years) with negative TRUS biopsy were enrolled Suspicious areas were identified by discrete low signal intensity in T2 on standard MRI. MRSI was interpreted by using spectral approach and given score of I (benign) to 5 (malignant). Suspicious voxels were localized for guided TRUS biopsy. All patients underwent sextant TRUS biopsies with up to four additional biopsies targeted at suspicious sites. Diagnostic accuracy of MRI/MRSI in patient-by-patient and voxel-by-core were analyzed.

RESULTS

Prostate cancer was detected in 2 of 21 patients (9.5%). The sensitivity, specificity, PPV, NPV and accuracy of combined MRI/MRSI for detection of prostate cancer were 100%, 84%, 40%, 100%, and 86%, respectively. The site of positive biopsy correlated correctly with voxels were 80%, 85%, 21%, 99% and 85% on sensitivity, specificity, PPV, NPV and accuracy, respectively.

CONCLUSION

MRI/MRSI have the potential to guide biopsy to cancer foci in patients with persistently high PSA levels and prior negative TRUS biopsy results.

Combined hepatocellular and cholangiocarcinoma: CT findings with emphasis on multiphasic helical CT

OBJECTIVE

To describe CT findings of patients with combined hepatocellular carcinoma and cholangiocarcinoma (HCC-CC) in correlation with clinical data and histopathological results.

MATERIAL AND METHOD

Ten from 31 cases whose CT study was available were reviewed retrospectively in the aspect of imaging findings, clinical data, and pathological results.

RESULTS

Most of the tumors were hypodense solitary mass with gradually enhanced after contrast administration. Bile duct dilatation was observed in two cases. The overall CT findings were more similar to CC rather than HCC despite the pathological result showing predominant HCC component. Serum alpha-fetoprotein level was normal or mildly elevated while an elevated concentration of carbohydrate antigen 19-9 was observed. Hepatitis profiles showed positive to hepatitis B virus infection in four cases and hepatitis C virus infection in one case.

CONCLUSION

The diagnosis of combined HCC-CC should be considered if the tumor has similar findings to CC without bile duct dilatation on cirrhotic liver and the patient has normal or low rising of the AFP level with or without elevated CA 19-9 level. In non-cirrhotic liver, the finding is non-specific.

Effect of Transcatheter Hepatic Arterial Embolization on Angiogenesis in an Animal Model

OBJECTIVES

Transcatheter arterial embolization (TAE) is used for the treatment of patients with malignant liver tumors. However, the proangiogenesis effect of TAE-associated hypoxia has not been adequately studied. The goal of this study was to determine angiogenic activity in tumors subjected to TAE by evaluating the tumor microvessel density (MVD).

MATERIALS AND METHODS

Mammary cancer 13762 NF tumor cells were inoculated into the livers of male Sprague-Dawley rats. TAE was performed 12-14 days after tumor inoculation. Rats were divided into 4 groups on the basis of treatment type. Control group animals (n = 16) were subjected to sham TAE without polyvinyl alcohol (PVA) particles. Animals in the other 3 groups were subjected to TAE with 1 (n = 11), 2 (n = 8), or 3 (n = 10) mg of PVA particles. Rats were killed 3-6 hours or 2 or 3 days after embolization, and the liver tumor tissues were dissected and frozen in liquid nitrogen. Tumor tissue slides were prepared, stained with CD-31, and evaluated for MVD. Blood samples collected just before sacrificing the animals were used to measure serum vascular endothelial growth factor (VEGF) levels.

RESULTS

Tumors treated with TAE showed varying degrees of central necrosis with residual viable tumor cells in the periphery. Tumor MVD in animals treated with TAE was significantly higher than that in the control group (23.6 versus 17.5; P = 0.001). Although the MVD in animals treated with TAE using 1 mg of PVA was higher than that in the control group, this difference was not statistically significant. TAE using 2 mg of PVA resulted in a significant increase in tumor MVD (25.9 versus 17.5; P = 0.007). Use of 3 mg of PVA did not result in any further increase in MVD. There was a significant increase in tumor MVD in the animals killed 2 or 3 days after TAE compared with the control group (24.5 versus 17.5; P = 0.002). The animals treated with TAE showed a statistically significant increase in VEGF levels compared with the control group.

CONCLUSIONS

TAE of hepatic tumors results in the stimulation of angiogenesis in the residual viable tumor, which could have an adverse effect on the therapeutic efficacy of TAE.

Lymphomatous involvement of gastrointestinal tract: evaluation by positron emission tomography with (18)F-fluorodeoxyglucose

AIM

To demonstrate the (18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) findings in patients with non-Hodgkinos lymphoma (NHL) involving the gastrointestinal (GI) tract and the clinical utility of modality despite of the known normal uptake of FDG in the GI tract.

METHODS

Thirty-three patients with biopsy-proven gastrointestinal NHL who had undergone FDG-PET scan were included. All the patients were injected with 10-15 mCi FDG and scanned approximately 60 min later with a CTI/Siemens HR (+) PET scanner. PET scans were reviewed and the maximum standard uptake value (SUV(max)) of the lesions was measured before and after the treatment, if data were available and compared with histologic diagnoses.

RESULTS

Twenty-five patients had a high-grade lymphoma and eight had a low-grade lymphoma. The stomach was the most common site of the involvement (20 patients). In high-grade lymphoma, PET showed focal nodular or diffuse hypermetabolic activity. The average SUV(max)+/-SD was 11.58+/-5.83. After the therapy, the patients whose biopsies showed no evidence of lymphoma had a lower uptake without focal lesions. The SUV(max)+/-SD decreased from 11.58+/-5.83 to 2.21+/-0.78. In patients whose post-treatment biopsies showed lymphoma, the SUV(max)+/-SD was 9.42+/-6.27. Low-grade follicular lymphomas of the colon and stomach showed diffuse hypermetabolic activity in the bowel wall (SUV(max) 8.2 and 10.3, respectively). The SUV(max) was 2.02-3.8 (mean 3.02) in the stomach lesions of patients with MALT lymphoma. ONCLUSION: (18)F-FDG PET contributes to the diagnosis of high-grade gastrointestinal non-Hodgkin's lymphoma, even when there is the normal background FDG activity. Furthermore, the SUV plays a role in evaluating treatment response. Low-grade NHL demonstrates FDG uptake but at a lesser intensity than seen in high-grade NHL.

Functional CT quantification of tumor perfusion after transhepatic arterial embolization in a rat model

PURPOSE

To quantify tumor perfusion after transcatheter arterial embolization (TAE) with functional computed tomography (CT) and to validate the reproducibility of quantification measurements.

MATERIALS AND METHODS

This study was conducted in accordance with an institutional animal care and use committee-approved protocol. Sixteen rats with liver tumors underwent TAE with 1 mg (group 1) or 3 mg (group 2) of polyvinyl alcohol particles. In each group, four rats underwent functional CT immediately after TAE (day 0) and four others underwent functional CT 2 days after TAE (day 2). Another four rats served as control rats. Blood flow (BF), blood volume (BV), mean transit time (MTT), and permeability-surface area product were measured by using a functional CT software program. For evaluation of reproducibility, six additional rats with mammary tumors underwent functional CT twice, with examinations 2 hours apart. The mixed-effect model was used to assess the TAE treatment effect, and the Pearson correlation test was used to determine measurement reproducibility.

RESULTS

With the exception of BF in group 1 on day 2 (P = .41), BF and BV values in both groups on both days were significantly lower than BF and BV values in the control rats (with P values ranging from .018 to <.001). BF was significantly lower in group 2 than in group 1 on days 0 and 2 (P = .043 and P = .02, respectively). BV was significantly lower on day 2 than on day 0 in group 2 (P = .016). MTT was generally inversely related to BF. MTTs in group 2 on days 0 and 2 were significantly longer than those in the control rats (P < .001 and P = .03, respectively), and MTT was shorter on day 2 than on day 0 in group 2 (P = .02). Permeability-surface area product changes were similar to BF changes. There were no significant differences (P values ranged from .2 to .5) between perfusion parameters in the reproducibility study.

CONCLUSION

The results of this study validate the use of functional CT in the quantification of tumor perfusion after TAE and the reproducibility of such quantification measurements.

Functional CT for Quantifying Tumor Perfusion in Antiangiogenic Therapy in a Rat Model

PURPOSE

To determine the histologic basis of perfusion parameters measured at functional computed tomography (CT) and to examine the relationship between changes in perfusion and changes in histologic parameters after antiangiogenic therapy in a rat model.

MATERIALS AND METHODS

This study had institutional animal care and use committee approval. Among 20 Fischer rats with implanted FN13762 tumors in the liver, 10 were treated with SU5416, a tyrosine kinase inhibitor of vascular endothelial growth factor receptor, and 10 were treated with the diluent only as control rats. Six rats chosen at random from each group underwent functional CT for the measurement of tumor blood flow, blood volume, mean transit time, and permeability-surface area product. Tumor tissue slides corresponding to functional CT sections were examined to measure tumor microvascular density, number of luminal vessels, vascular perimeter, and vascular area. Two-tailed Student t testing was used to determine differences in growth, numbers of metastases to major organs, vascularity, and perfusion between SU5416-treated and control tumors. Pearson correlation coefficients were used to investigate relationships between vascular parameters.

RESULTS

Mean tumor volume and number of metastases, respectively, were lower in SU5416-treated rats than in control rats (1580 mm3 +/- 830 [standard deviation] vs 2330 mm3 +/- 960 and 22.4 +/- 11.0 vs 35.2 +/- 17.3); however, these differences were not significant (P = .084 and P = .079). Mean tumor microvascular density was significantly lower in SU5416-treated rats than in control rats (6.4 vessels per field +/- 4.6 vs 17.2 vessels per field +/- 7.5, P < .001); however, vessel perimeter and vessel area, respectively, were significantly larger in treated rats than in control rats (470 microm per field +/- 320 vs 360 microm per field +/- 270, P = .02; and 4010 microm2 per field +/- 2990 vs 2230 microm2 per field +/- 1750, P = .001). Significant correlations were observed between microvascular density and vessel perimeter and area (r = 0.59 and r = 0.25, respectively; P < .01 for both) in SU5416-treated tumors but not control tumors. Blood flow, blood volume, and permeability-surface area product at functional CT were significantly higher in SU5416-treated tumors than in control tumors (P < .001 for all).

CONCLUSION

These results validate the idea that functional CT can help quantify the perfusion function of mature vessels but not changes in microvessel density in antiangiogenic therapy.

Bile duct complications of hepatic arterial infusion chemotherapy evaluated by helical CT

AIM

To describe the imaging findings of bile duct complications of hepatic arterial infusion chemotherapy (HAIC) using helical CT, to set diagnostic criteria, to develop a CT grading system, and to correlate these with clinical findings and laboratory data.

METHODS

Follow-up helical CT of the abdomen was performed every 3 months for 60 patients receiving HAIC. Three radiologists reviewed all CT studies before and after treatment, using either the picture archiving and communication system or hard copies. The findings of bile duct abnormalities were correlated with findings from other imaging techniques, clinical symptoms and laboratory data.

RESULTS

Bile duct abnormalities developed in 34 (57%) of cases either during HAIC or 1 to 12 months after treatment. In 14 (41%) of these 34 patients, enhancement of the hepatic parenchyma along the dilated bile duct or in the segmental or lobar distribution was observed. In 43 cases (72%), normal or abnormal alkaline phosphatase levels were consistent with normal or abnormal CT findings, respectively. Increasing alkaline phosphatase and bilirubin levels were related to CT grade.

CONCLUSION

Imaging findings of bile duct complications of HAIC are similar to those of primary sclerosing cholangitis, and correlate well with abnormal clinical and laboratory data. In the presence of such clinical abnormalities, thin-section helical CT with careful review of the imaging studies helps to determine the correct diagnosis, monitor the changes and guide appropriate treatment.

Systematic approach to the analysis of cross-sectional imaging for surveillance of recurrent colorectal cancer

Recurrent disease in colorectal cancer occurs in approximately 50% of patients who undergo a "curative" operation. Tumor recurrence may occur locally (at the anastomotic site), in the mesentery or mesocolon adjacent to the post-operative site, in the nodal echelon downstream to the post-operative site, and as distant metastases to the peritoneal cavity, liver or lung. Local recurrence at the anastomosis is frequently diagnosed at follow-up endoscopic examinations as part of screening for metachronous lesions. Other types of recurrences require imaging studies, most frequently CT or MR imaging to diagnose. We developed an approach to analyze imaging obtained after curative resection of colorectal cancer. Our approach is based on the knowledge of patterns of disease spread, of types of surgical procedures and of pathologic staging. Using this approach has the potential to detect recurrent disease at an early stage because the locoregional and nodal spread of this disease is predictable. Early diagnosis of recurrent disease, even in asymptomatic cases, allows for more effective treatment that can improve the long-term survival of these patients.

The efficacy of roselle (Hibicus sabdariffa Linn.) flower tea as oral negative contrast agent for MRCP study

OBJECTIVE

To evaluate the efficacy of roselle flower tea (RFT) administration as oral negative contrast agent for MRCP study.

MATERIAL AND METHOD

Roselle flower tea was prepared by packing 4,000 mg of dry ground roselle flower in a tea bag and soaked with 480 ml of hot distilled water RFT was tested in phantom, volunteer subjects and was studied in patients for MRCP study. Quanlitative analysis was made by evaluation of the conspicuity of biliary system after RFT administration. Quantitative comparison was performed by comparing the contrast-to-noise ratio between each part of the biliary system with stomach and duodenum.

RESULTS

Roselle flower tea can effectively reduce signal intensity of the stomach and duodenum. There was statistically significant (p < 0.05) improvement in conspicuity of the common bile duct. There was slight improvement of conspicuity of common hepatic duct, ampulla and main pancreatic duct. Contrast-to-noise ratios were all statistically significantly improved. RFT contains 0.6 mg of iron and 1.28 mg of manganese content.

CONCLUSION

Roselle flower tea is a very efficient oral negative contrast agent. It is natural, safe, inexpensive and palatable for oral administration.

FDG PET in the Evaluation of Treatment for Lymphoma: Clinical Usefulness and Pitfalls

Positron emission tomography (PET) with 2-[fluorine-18] fluoro-2-deoxy-d-glucose (FDG) may play an important role in the evaluation and management of malignant lymphoma. FDG uptake is predictive of therapeutic response during the course of treatment. After completion of chemotherapy, residual abnormalities representing either residual tumor or necrotic or fibrotic tissue are not uncommon, and FDG PET may be more accurate than computed tomography (CT) or magnetic resonance imaging in assessing residual disease and identifying patients who require more intense treatment. However, posttreatment FDG PET does not help exclude the presence of minimal residual disease, which may lead to disease relapse. Furthermore, FDG is not a tumor-specific substance, and increased accumulation may be seen in a variety of benign entities and scenarios (eg, infection, drug toxicity, granulocyte colony-stimulating factor therapy, radiation therapy, physiologic activity, postoperative or postbiopsy changes, fracture, degenerative change, injection leakage), which may yield false-positive findings. Nevertheless, recognition of these entities and correlation of FDG PET findings with clinical and other radiologic findings-especially those at combined PET and CT or PET-CT fusion imaging-allows improved diagnostic accuracy. If the interpretation of positive findings is exceptionally difficult, short-term follow-up may be helpful.

Quantification of angiogenesis by functional computed tomography in a Matrigel model in rats

RATIONALE AND OBJECTIVES

The aim was to evaluate functional computed tomography (fCT) in the quantification of angiogenesis by comparing the tissue perfusion parameters measured by CT perfusion (CTP) software with histologic vascular parameters in a Matrigel model in rats. It was hypothesized that tissue perfusion parameters and histologic vascular parameters are related.

MATERIALS AND METHODS

In vivo angiogenesis assays were performed using Matrigel supplemented with escalating doses (0 ng [control group], 250 ng, and 1,000 ng) of recombinant rat vascular endothelial growth factor (VEGF164) subcutaneously injected into the backs of Sprague Dawley rats. On day 7, rats with Matrigel plug underwent fCT following a bolus injection of iodinated contrast medium. Using CTP software, fCT parameters were generated (blood flow [BF], blood volume [BV], mean transit time, and permeability-surface area product) and functional maps on the basis of a distributed parameter tracer kinetic model, the adiabatic approximation to the tissue homogeneity model. The animals were then sacrificed. Matrigel plug was sectioned into slices corresponding to the CT scan plane and stained with CD31 immunohistochemical stain. Histologic vascular parameters, including microvascular density (MVD), vessel number (VN), vascular area, and vascular perimeter, were measured. CTP and histologic parameters were correlated.

RESULTS

The Matrigel plugs with the 1,000-ng VEGF group exhibited a higher MVD than the 250-ng VEGF and control groups (P < .05). VN differed significantly between the control versus the 250-ng VEGF groups and 250-ng versus 1,000-ng VEGF groups (P < .05), with the highest VN in the 250-ng VEGF group. BF, mean transit time, and permeability-surface area product each differed significantly to VEGF levels. Changes in BF and BV did not correspond with increases in MVD or VN; however, in the 250-ng VEGF group, there was a strong positive correlation (r = 0.9) between BV and VN, vascular area, and vascular perimeter, which was not seen in the control or 1,000-ng VEGF group. All fCT parameters significantly correlated with each other (P < .05), with strong correlations between BF and mean transit time (r = -0.7) and between BF and permeability-surface area product (r = 0.7) and a weak correlation between BF and BV (r = 0.3).

CONCLUSION

These results validate the VEGF-induced endothelial cell in a rat Matrigel model. In addition, histologic vascular parameter MVD does not correlate with fCT parameters measured by CTP software.

Determination of the thecal sac ending using magnetic resonance imaging: clinical applications in craniospinal irradiation

PURPOSE

To determine level of the thecal sac ending in unaffected individuals of young age-group and in patients with cerebrospinal fluid (CSF) seeding tumor using Magnetic Resonance Imaging (MRI).

MATERIAL AND METHOD

MRI of the lumbosacral spine of 253 cases (age range 1-40 years) had been reviewed. Of these, 20 cases were known having CSF seeding tumors. Two hundred and thirty-three cases of unaffected individuals were used as control group. Sagittal MR images were used to determine the level of thecal sac ending by referencing on the corresponding vertebral body and intervertebral disc.

RESULTS

The range of the thecal sac ending level in unaffected population varied from the lower one-third of L5 to the middle one-third of S3. About 97% of cases, the distal end of thecal sac terminated at the S2-3 intervertebral disc space or higher. In patients with CSF seeding tumor, the range of thecal sac ending was from the middle one-third of L5 to the S2-3 intervertebral disc space. There was no statistically significant difference of thecal ending level between unaffected group and patients with CSF seeding tumors (p=0.19).

CONCLUSION

Placing inferior border of radiation field at the middle one-third of S3 vertebra would help to cover the entire subarachnoid space in all cases. Without MR machine, this study may be used as a general guideline for placing the inferior border for spinal irradiation.