Delayed Enhancement Pattern Research Articles

A case of unresectable intrahepatic cholangiocarcinoma with a germline BRCA1 mutation.

Intrahepatic cholangiocarcinoma (ICC) is a malignant liver tumor with poor prognosis. Various mutations in cancer-predisposing genes have been reported in ICC, and germline BRCA1/2 mutations, which are the causative genes for hereditary breast and ovarian cancer syndrome (HBOC), have been reported in many patients with ICC. Here, we report a case of unresectable ICC with a germline BRCA1 mutation. A 73-year-old man was found to have a mass in the left lobe of the liver on abdominal ultrasonography during a medical check-up and was referred to our institution. Contrast-enhanced computed tomography revealed a 30-mm mass with a delayed enhancement pattern, tumor invasion into the major blood vessels, and enlarged regional lymph nodes. Ultrasound-guided percutaneous tumor biopsy revealed a well-differentiated adenocarcinoma, and the patient was diagnosed with clinical Stage IIIB ICC. Systemic chemotherapy with gemcitabine and cisplatin was initiated because of the unresectable nature of the disease. Regarding family history, his eldest daughter was diagnosed with HBOC with a germline BRCA1 mutation at the time of breast cancer surgery, and she developed pancreatic cancer seven years later. The patient underwent BRCA1 single-site analysis and was diagnosed with HBOC with a germline BRCA1 mutation.

Assessment of Meningeal Lymphatics in the Parasagittal Dural Space: A Prospective Feasibility Study Using Dynamic Contrast-Enhanced Magnetic Resonance Imaging.

Meningeal lymphatic vessels are predominantly located in the parasagittal dural space (PSD); these vessels drain interstitial fluids out of the brain and contribute to the glymphatic system. We aimed to investigate the ability of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in assessing the dynamic changes in the meningeal lymphatic vessels in PSD. Eighteen participants (26-71 years; male:female, 10:8), without neurological or psychiatric diseases, were prospectively enrolled and underwent DCE-MRI. Three regions of interests (ROIs) were placed on the PSD, superior sagittal sinus (SSS), and cortical vein. Early and delayed enhancement patterns and six kinetic curve-derived parameters were obtained and compared between the three ROIs. Moreover, the participants were grouped into the young (< 65 years; n = 9) or older (≥ 65 years; n = 9) groups. Enhancement patterns and kinetic curve-derived parameters in the PSD were compared between the two groups. The PSD showed different enhancement patterns than the SSS and cortical veins (P < 0.001 and P < 0.001, respectively) in the early and delayed phases. The PSD showed slow early enhancement and a delayed wash-out pattern. The six kinetic curve-derived parameters of PSD was significantly different than that of the SSS and cortical vein. The PSD wash-out rate of older participants was significantly lower (median, 0.09; interquartile range [IQR], 0.01-0.15) than that of younger participants (median, 0.32; IQR, 0.07-0.45) (P = 0.040). This study shows that the dynamic changes of meningeal lymphatic vessels in PSD can be assessed with DCE-MRI, and the results are different from those of the venous structures. Our finding that delayed wash-out was more pronounced in the PSD of older participants suggests that aging may disturb the meningeal lymphatic drainage.

Combined arterial and delayed enhancement patterns of MRI assist in prognostic prediction for intrahepatic mass-forming cholangiocarcinoma (IMCC).

This study valued MR delayed enhancement pattern in predicting postoperative prognosis of intrahepatic mass-forming cholangiocarcinoma (IMCC). From 2011 to 2015, 231 patients of IMCC underwent DCE-MRI preoperatively. Enhancement patterns and MRI characteristics were evaluated. Recurrence and mortality data were compared among IMCCs with different enhancement patterns. Prognostic factor analysis was performed using preoperative and postoperative clinical-pathologic factors, as well as imaging findings. Fifty-six (24.2%), 142 (61.5%) and 33 (14.3%) tumors showed hypo, peripheral rim and diffuse hyper enhancement in AP. Fifty-six (24.2%), 81 (35.1%) and 94 (40.7%) tumors showed hypo, heterogeneous and uniform enhancement in DP. Patients with arterial diffuse hyper enhancement or delayed uniform enhancement IMCCs had lower preoperative CA19-9 levels, smaller tumor sizes and minor operations than the rest patients (p < 0.05) and they were less associated with lymph nodes metastasis, vascular invasion, necrosis or poor tumor differentiation (p < 0.05), therefore with higher overall and disease-free survival rates (p < 0.05). The combination of AP and DP increased the detection rate of patients with good prognosis in the arterial rim enhancement group. Multivariate analysis revealed the delayed enhancement pattern (hypo HR = 6.304/10.028 for DFS/OS; heterogenous HR = 4.579/4.972 for DFS/OS), multitude of lesions (HR = 1.6/1.5 for DFS/OS) and tumor sizes (HR = 1.6 for DFS) were independent prognostic factors. The uniform enhancement pattern in delayed MRI was an independent optimal prognostic factor for IMCCs and increased the detection rate of patients with good prognosis compared to the arterial diffuse hyper enhancement pattern.

Utilization of cardiac MRI for the assessment of suspected rejection with negative biopsy in heart transplant recipients

Abstract Background Heart transplant (HTx) patients can develop graft dysfunction (GD) without biopsy evidence of cell or antibody mediated rejection. Cardiac MRI (CMR) can detect inflammatory or infiltrative causes of cardiomyopathy however CMR findings in HTx recipients with GD have not been previously described. Purpose We sought to identify CMR characteristics of HTx patients with GD, and evaluate its additive value in its diagnosis and prognosis. Methods CMR has been performed routinely to evaluate GD at our institutions. There were 37 HTx recipients who presented with acute decline in left ventricular ejection fraction (LVEF) of &amp;lt;50% and &amp;gt;10% from baseline, with no biopsy evidence of rejection between 2007 and 2018. Coronary angiogram with IVUS was done to rule out allograft vasculopathy. Treatment of GD was per discretion of the treating clinician. Responders were defined as those with LVEF improvement &amp;gt;10% at 180 days or greater post-presentation. LV and RV indices, the presence and pattern of late gadolinium enhancement (LGE) were determined by CMR. Results There were 34% females and mean age at transplant was 49±13 years. Median time from HTx to GD was 1.2 years. Presenting symptoms were heart failure (n=25), cardiogenic shock (n=1) and 11 patients were asymptomatic. Mean LVEF at presentation was 37±12% and donor specific antibodies were detected in 38% patients. Most patients were treated with steroid bolus (n=29), and/or plasmapheresis (n=23). There were no major changes made in immunosuppression in 6 patients. Delayed enhancement MRI was performed with standard inversion-recovery (IR) gradient echo sequences, between 5 and 20 minutes after institutional-standard protocol administration of IV gadolinium contrast. Biventricular LGE was present in 18/37 (49%) patients with GD and was more prevalent in responders (57%, 13 of 23) than non-responders (35%, 5 of 14), although not statistically significant (p=0.21). There were two patterns of LGE noted: 1) Diffuse epicardial (10 patients out which 9 were responders) and 2) Patchy pattern with non-specific distribution (8 patients out of which 4 were responders). Myocardial edema by triple IR sequencing was seen in 6 patients, all having diffuse epicardial pattern of enhancement matching the delayed enhancement pattern. When comparing different treatment groups, among those treated for GD (n=31), 12 of 21 (57%) responders had LGE and 4 of 10 (40%) non-responders had LGE (p=0.37), a pattern similar to the broader population. Among those not treated for GD (n=6), 1 of 2 responders had LGE and 1 of 4 non-responders had LGE (p=0.5). Conclusion CMR identified inflammation as a potential cause of GD in approximately 50% of HTx patients. There are 2 distinct patterns of LGE observed in GD, diffuse epicardial (56%) and patchy (44%). Although the presence of LGE in itself is not associated with myocardial recovery, 90% of patients with a diffuse epicardial pattern have recovery of GD. Funding Acknowledgement Type of funding source: None

The Role of MRI in the Diagnosis of Papillary Thyroid Carcinoma with Hobnail Features: A Case-Control Study

Purpose—To evaluate whether Magnetic Resonance Imaging (MRI) preoperatively could be used as a potentially routine tool to recognize papillary thyroid carcinoma with hobnail features (HPTC). Methods—This retrospective study included 97 patients with confirmed papillary thyroid carcinoma (PTC) who underwent thyroid MRI examination one week before surgery between January 2014 and June 2017. The differences in age, sex, tumor size, each MRI feature (lesion shape; signal heterogeneity on T1WI, T2WI and diffusion weighted imaging (DWI); significantly high signal on T2WI, segmentation linear low signal on T2WI, T2WI lobulation, T2WI ripple-like performance; and early enhancement degree, delayed enhancement pattern) and apparent diffusion coefficient (ADC) values of HPTC and PTC without hobnail features (NHPTC) were determined. The evaluation indicators of significant MRI features were determined. Independent-samples t test, chi-square test, Fisher's exact test, nonparametric test, and analyses of receiver operating characteristic (ROC) curve were performed. Results—There were 10 patients with HPTCs and 81 patients with NHPTCs included in the study. Compared to the NHPTCs, the HPTCs had larger volumes (P = 0.025), more irregular shapes (P = 0.004), more heterogeneous T2WI and DWI signals (P = 0.028, 0.006, respectively), higher frequencies of significantly high signals on T2WI, segmentation linear low signals, lobulation and ripple-like performances (P = 0 000 all), and higher ADC values (P = 0 036). In addition, the delayed mass-like enhancement was more common in HPTCs (P = 0.046). Characteristics including significantly high signal on T2WI, segmentation linear low signal, lobulation, ripplelike performance and a size ≥2.15 cm have significant power to predict HPTCs. Characteristics including the absence of irregular shape, a heterogeneous signal on T2WI or a significantly high signal on T2WI have significant power to predict NHPTCs. Conclusions—HPTC lesions have unique MRI features distinct from NHPTCs and recognizing these features may help to assess the invasiveness of PTC preoperatively.

Detection and Classification of Myocardial Delayed Enhancement Patterns on MR Images with Deep Neural Networks: A Feasibility Study.

To evaluate whether deep neural networks trained on a similar number of images to that required during physician training in the American College of Cardiology Core Cardiovascular Training Statement can acquire the capability to detect and classify myocardial delayed enhancement (MDE) patterns. The authors retrospectively evaluated 1995 MDE images for training and validation of a deep neural network. Images were from 200 consecutive patients who underwent cardiovascular MRI and were obtained from the institutional database. Experienced cardiac MR image readers classified the images as showing the following MDE patterns: no pattern, epicardial enhancement, subendocardial enhancement, midwall enhancement, focal enhancement, transmural enhancement, and nondiagnostic. Data were divided into training and validation datasets by using a fourfold cross-validation method. Three untrained deep neural network architectures using the convolutional neural network (CNN) technique were trained with the training dataset images. The detection and classification accuracies of the trained CNNs were calculated with validation data. The 1995 MDE images were classified by human readers as follows: no pattern, 926; epicardial enhancement, 91; subendocardial enhancement, 458; midwall enhancement, 118; focal enhancement, 141; transmural enhancement, 190; and nondiagnostic, 71. GoogLeNet, AlexNet, and ResNet-152 CNNs demonstrated accuracies of 79.5% (1592 of 1995 images), 78.9% (1574 of 1995 images), and 82.1% (1637 of 1995 images), respectively. Deep learning with CNNs using a limited amount of training data, less than that required during physician training, achieved high diagnostic performance in the detection of MDE on MR images.© RSNA, 2019Supplemental material is available for this article.

Differentiation between Pure Mucinous Breast Carcinomas and Fibroadenomas with Strong High-Signal Intensity on T2-Weighted Images from Dynamic Contrast-Enhanced Magnetic Resonance Imaging

Objective: This study aimed to identify characteristics that can differentiate between pure mucinous breast carcinomas (PMBCs) and fibroadenomas (FAs) with strong high-signal intensity on T2-weighted images (T2-SHi) from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). Methods: The DCE-MRI tumor characteristics were compared and analyzed between 35 PMBCs and 70 FAs with T2-SHi. Results: Multivariate analysis revealed that delayed enhancement pattern was the only significant independent predictor (p = 0.007). Conclusion: A delayed enhancement pattern is the most reliable characteristic for differentiating PMBCs from FAs with T2-SHi from DCE-MRI.

Small bowel neoplasms: enhancement patterns and differentiation using post-contrast multiphasic multidetector CT.

The purpose of the present study was to analyze the enhancement patterns of small bowel neoplasms on post-contrast multiphasic multidetector CT and to assess the diagnostic capacity for differentiating five tumor types. We performed a retrospective study of data on 92 small bowel neoplasms. The neoplasms were categorized into five groups according to pathology findings, not imaging findings (23 adenocarcinomas; 22 lymphomas; 19 metastases; 18 gastrointestinal stromal tumors [GIST]; 10 neuroendocrine tumors [NET]). GIST and NET demonstrated a hypervascular pattern in the multiphasic dynamic study. Adenocarcinoma and lymphoma showed a delayed enhancement pattern. Metastasis was classified as an intermediate enhancement pattern. The receiver operating characteristic analyses revealed that attenuation thresholds could be set with acceptable accuracies for most of the small bowel neoplasms. Multiphasic dynamic studies may have the potential to improve the diagnostic capacity of multidetector CT for small bowel neoplasms.

Retrospective analysis of MR imaging characteristics and demographic characteristics of Tropical Endomyocardial fibrosis in a tertiary care centre in South India

Background Cardiac MR is helpful in the diagnosis and prognosis of endomyocardial fibrosis[EMF]. Among the two types of endomyocardial fibrosis, tropical endomyocardial fibrosis is geographically restricted to tropical parts of Africa, Latin America and in the southern districts of India, especially along the coastal region of Kerala. Various toxic and environmental factors were postulated as the etiopathogenesis of tropical endomyocardial fibrosis. Endomyocardial fibrotic wall thickening of apex and subvalvular regions of one or both ventricles results in restrictive pattern. Typical delayed enhancement pattern is the subendocardial enhancement which is prominent in the apex and extending up to the subvalvular regions

Differential MR delayed enhancement patterns of chronic myocardial infarction between extracellular and intravascular contrast media.

ObjectivesBecause the distribution volume and mechanism of extracellular and intravascular MR contrast media differ considerably, the enhancement pattern of chronic myocardial infarction with extracellular or intravascular media might also be different. This study aims to investigate the differences in MR enhancement patterns of chronic myocardial infarction between extracellular and intravascular contrast media.Materials and MethodsTwenty pigs with myocardial infarction underwent cine MRI, first pass perfusion MRI and delayed enhancement MRI with extracellular or intravascular media at four weeks after coronary occlusion. Myocardial blood flow (MBF) was determined with microsphere measurement. The infarction histopathological changes were evaluated by hematoxylin and eosin staining and Masson's trichrome method.ResultsCine MRI revealed the reduced wall thickening in chronic infarction compared with normal myocardium. Moreover, significant wall thinning in chronic infarction was observed in cine MRI. Peak first-pass signal intensity didn’t significantly differ between chronic infarction and normal myocardium no matter what kinds of contrast media. At the following delayed enhancement phase, extracellular media-enhanced signal intensity was significantly higher in chronic infarction than in normal myocardium. Conversely, intravascular media-enhanced signal intensity was almost equivalent among chronic infarction and normal myocardium. At four weeks after infarction, MBF in chronic infarction approached to that in normal myocardium. Large thick-walled vessels were detected at peri-infarction zones. The cardiomyocytes were replaced by scar tissue consisting of dilated blood vessels and discrete fibers of collagen.ConclusionsChronic infarction was characterized by the significantly reduced wall thickening and the definite wall thinning. First-pass myocardial perfusion defect was not detected in chronic infarction with two media due to the significantly recovered MBF and well-developed collateral vessels. Infarction remodeling enlarged the extracellular compartment, which was available for extracellular media but not accessible to intravascular media. Extracellular media identified chronic infarction as the hyper-enhancement; nonetheless, intravascular media didn’t provide delayed enhancement.

Magnetic Resonance Imaging Features of Adenosis in the Breast.

PurposeAdenosis lesions of the breast, including sclerosing adenosis and adenosis tumors, are a group of benign proliferative disorders that may mimic the features of malignancy on imaging. In this study, we aim to describe the features of breast adenosis lesions with suspicious or borderline findings on dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).MethodsIn our database, we identified 49 pathologically proven breast adenosis lesions for which the final assessment of the breast MRI report was classified as either category 4 (n=45) or category 5 (n=4), according to the Breast Imaging Reporting and Data System (BI-RADS) published by the American College of Radiology (ACR). The lesions had a final diagnosis of either pure adenosis (n=33, 67.3%) or mixed adenosis associated with other benign pathologies (n=16, 32.7%).ResultsOf the 49 adenosis lesions detected on DCE-MRI, 32 (65.3%) appeared as enhancing masses, 16 (32.7%) as nonmass enhancements, and one (2.1%) as a tiny enhancing focus. Analysis of the enhancing masses based on the ACR BI-RADS lexicon revealed that among the mass descriptors, the most common features were irregular shape in 12 (37.5%), noncircumscribed margin in 20 (62.5%), heterogeneous internal pattern in 16 (50.0%), rapid initial enhancement in 32 (100.0%), and wash-out delayed en-hancement pattern in 21 (65.6%). Of the 16 nonmass enhancing lesions, the most common descriptors included focal distribution in seven (43.8%), segmental distribution in six (37.5%), clumped internal pattern in nine (56.3%), rapid initial enhancement in 16 (100.0%), and wash-out delayed enhancement pattern in eight (50.0%).ConclusionAdenosis lesions of the breast may appear suspicious on breast MRI. Awareness of these suspi-cious-appearing features would be helpful in obviating unnecessary breast biopsies.

Pathological mechanism for delayed hyperenhancement of chronic scarred myocardium in contrast agent enhanced magnetic resonance imaging.

ObjectivesTo evaluate possible mechanism for delayed hyperenhancement of scarred myocardium by investigating the relationship of contrast agent (CA) first pass and delayed enhancement patterns with histopathological changes.Materials and MethodsEighteen pigs underwent 4 weeks ligation of 1 or 2 diagonal coronary arteries to induce chronic infarction. The hearts were then removed and perfused in a Langendorff apparatus. The hearts firstly experienced phosphorus 31 MR spectroscopy. The hearts in group I (n = 9) and II (n = 9) then received the bolus injection of Gadolinium diethylenetriamine pentaacetic acid (0.05 mmol/kg) and gadolinium-based macromolecular agent (P792, 15 µmol/kg), respectively. First pass T2 * MRI was acquired using a gradient echo sequence. Delayed enhanced T1 MRI was acquired with an inversion recovery sequence. Masson's trichrome and anti- von Willebrand Factor (vWF) staining were performed for infarct characterization.ResultsWash-in of both kinds of CA caused the sharp and dramatic T2 * signal decrease of scarred myocardium similar to that of normal myocardium. Myocardial blood flow and microvessel density were significantly recovered in 4-week-old scar tissue. Steady state distribution volume (ΔR1 relaxation rate) of Gd-DTPA was markedly higher in scarred myocardium than in normal myocardium, whereas ΔR1 relaxation rate of P792 did not differ significantly between scarred and normal myocardium. The ratio of extracellular volume to the total water volume was significantly greater in scarred myocardium than in normal myocardium. Scarred myocardium contained massive residual capillaries and dilated vessels. Histological stains indicated the extensively discrete matrix deposition and lack of cellular structure in scarred myocardium.ConclusionsCollateral circulation formation and residual vessel effectively delivered CA into scarred myocardium. However, residual vessel without abnormal hyperpermeability allowed Gd-DTPA rather than P792 to penetrate into extravascular compartment. Discrete collagen fiber meshwork and loss of cellularity enlarged extracellular space accessible to Gd-DTPA, resulting in the delayed hyper-enhanced scar.

Characteristics and outcome of enhancing foci followed on breast MRI with management implications

To evaluate the risk of cancer of an enhancing focus identified at breast magnetic resonance imaging (MRI) by determining the positive predictive value (PPV) associated with specific characteristics of an enhancing focus. Retrospective, institutional review board-approved review of the database identified 111 consecutive patients who underwent short-term follow-up of 136 enhancing foci in 2008. Kinetic analysis (delayed enhancement pattern) and other characteristics, such as interval change and T2 signal intensity, were evaluated to calculate the PPV for malignancy. The overall malignancy rate of an enhancing focus was 2.9% [4/136, 95% confidence interval (CI): 0.9-7.6%]. Kinetic analysis showed no statistical difference in PPV between foci with washout enhancement [5.1% (2/39)] versus persistent enhancement [3.2% (2/62); Fisher's exact test, p=0.6180]. PPV of a T2 hypointense focus was 8.7% (4/46); PPV of a new focus was 13.6% (3/22); PPV of an enlarging focus was 6.7%, (1/15). The combination of a focus being new and T2 hypointense had the highest PPV for malignancy (27.2%, 3/11, 95% CI: 9.2-57.1%). Kinetic analysis was not specific for malignancy and should not be used solely to guide management. A new enhancing focus with T2 hypointensity had a high PPV for malignancy and may warrant immediate biopsy.

High prevalence of atypical delayed enhancement in alkaptonuria

Background Alkaptonuria is a rare autosomal recessive metabolic disorder with an incidence of 1 case in 250,000 to 1 million live births. This genetic abnormality involves the tyrosine metabolism pathway which results in homogentisic acid accumulation throughout various tissues, including the heart. The purpose of this study is to prospectively determine the prevalence of cardiovascular abnormalities characterized by MRI in patients with alkaptonuria. Methods A group of 57 consecutive adult patients with laboratory confirmed alkaptonuria were referred for evaluation including transthoracic echocardiography and cardiac MRI, which included cine and phase contrast imaging at either 1.5T or 3T. Phase-sensitive inversion-recovery delayed enhancement imaging was performed after gadolinium-DTPA contrast administration. Late gadolinium enhancement patterns were determined by consensus read between two experienced cardiologists using a 17-segment model. Results Overall, 56 completed cine MRI, 53 received gadolinium contrast and 1 subject experienced claustrophobia precluding any imaging. Of the 56 who had CMR imaging, 77% (41 of 56) were male and the average age was 49 ± 12 years old. The prevalence of atypical delayed enhancement was 70% (37 of 53) and predominately involved the right ventricular insertion point (84%, 31 of 37 patients). Other delayed enhancement patterns included midwall (30%, 11 of 37), near aortic root (30%, 11 of 37), focal nodular (11%, 4 of 37), mitral papillary muscle involvement (8%, 3 of 37), and patchy/intermediate (5%, 2 of 37). Involvement of the right ventricular point has been associated with pulmonary hypertension; however, this group of alkaptonuria patients had normal estimated right ventricular systolic pressures measured on echocardiography performed within 1 day (median). The number of segments with atypical delayed enhancement was 2.7 ± 1.4 per patient. The prevalence of any atypical delayed enhancement trended higher for females vs. males (86% vs. 62%, p = NS) and was not associated with age. One subject had subendocardial delayed enhancement in a coronary artery distribution consistent with myocardial infarction. Conclusions Myocardial fibrosis based on late gadolinium enhancement abnormalities, especially involving the right ventricle insertion site, are common in patients with alkaptonuria despite not having pulmonary hypertension or cardiac structural abnormalities and suggests myocardial involvement due to this metabolic disorder. Further study is required to determine the etiology and clinical significance.

A simple and robust classification tree for differentiation between benign and malignant lesions in MR-mammography

In the face of multiple available diagnostic criteria in MR-mammography (MRM), a practical algorithm for lesion classification is needed. Such an algorithm should be as simple as possible and include only important independent lesion features to differentiate benign from malignant lesions. This investigation aimed to develop a simple classification tree for differential diagnosis in MRM. A total of 1,084 lesions in standardised MRM with subsequent histological verification (648 malignant, 436 benign) were investigated. Seventeen lesion criteria were assessed by 2 readers in consensus. Classification analysis was performed using the chi-squared automatic interaction detection (CHAID) method. Results include the probability for malignancy for every descriptor combination in the classification tree. A classification tree incorporating 5 lesion descriptors with a depth of 3 ramifications (1, root sign; 2, delayed enhancement pattern; 3, border, internal enhancement and oedema) was calculated. Of all 1,084 lesions, 262 (40.4%) and 106 (24.3%) could be classified as malignant and benign with an accuracy above 95%, respectively. Overall diagnostic accuracy was 88.4%. The classification algorithm reduced the number of categorical descriptors from 17 to 5 (29.4%), resulting in a high classification accuracy. More than one third of all lesions could be classified with accuracy above 95%. • A practical algorithm has been developed to classify lesions found in MR-mammography. • A simple decision tree consisting of five criteria reaches high accuracy of 88.4 %. • Unique to this approach, each classification is associated with a diagnostic certainty. • Diagnostic certainty of greater than 95 % is achieved in 34 % of all cases.

DC Bead Transarterial Chemoembolization Is Effective in Hepatocellular Carcinoma Refractory to Conventional Transarteral Chemoembolization: A Pilot Study

Background/AimsTo determine if hepatocellular carcinoma refractory to conventional transarterial chemoembolization (TACE) responds to TACE with DC beads.MethodsBetween July 2008 to June 2010, 435 patients underwent TACE. Of these, 10 patients who had tumors refractory to conventional TACE and who thus were treated with TACE with DC beads were enrolled in this study. The treatment response after TACE with DC beads was evaluated according to the modified Response Evaluation Criteria in Solid Tumors (mRECIST) and the Response Evaluation Criteria in Cancer of the Liver (RECICL).ResultsTen tumors were treated in 10 patients. Using the mRECIST and the RECICL, a complete response was observed in four (40%) of the tumors, and six tumors (60%) showed a partial response. Eight (80%) out of 10 HCCs showed delayed enhancement patterns upon angiography, and better responses were observed in these cases following DC bead treatment. The adverse effects of treatment with DC beads became tolerable.ConclusionsTACE with DC beads was effective for HCCs refractory to conventional TACE, and this treatment elicited a better response, especially when the tumors were small and showed a delayed enhancement pattern upon angiography.

Dual-Phase Computed Tomography for Assessment of Pancreatic Fibrosis and Anastomotic Failure Risk Following Pancreatoduodenectomy

IntroductionDelayed or decreased computed tomography (CT) enhancement characteristics in pancreatic fibrosis have been described. MethodsA review of 157 consecutive patients with preoperative dual-phase CT between 2004 and 2009 was performed. Pancreatic CT attenuation upstream from the tumor was measured in the pancreatic and hepatic imaging phases. The ratio of the mean CT attenuation value [hepatic to pancreatic phase; late/early (L/E) ratio] and histological grade of pancreatic fibrosis was correlated with the development of a clinically relevant pancreatic anastomotic failure (PAF) and other clinical parameters. ResultsA clinically relevant PAF was observed in 21 patients (13.4%) with morbidity and mortality of 39.5% and 0%, respectively. The PAF group showed maximum enhancement in the pancreatic and washout in the hepatic CT phase, while the no PAF group showed a delayed enhancement pattern. Degree of pancreatic fibrosis and L/E ratio were significantly lower for the PAF group than the no PAF group (0.86±0.14 vs. 1.09 ± 0.24; P < 0.0001 and 21.0±17.9 vs. 40.4 ± 29.8; P < 0.0001); fewer PAF patients showed an atrophic histological pattern (14% vs. 39%; P = 0.046). The L/E ratio was positively correlated with pancreatic fibrosis. Pancreatic fibrosis and L/E ratio increased with larger duct size (P < 0.001), the presence of diabetes (P < 0.05), and the surgeon’s assessment of pancreas firmness (P < 0.001). In multivariate analyses, L/E ratio and body mass index were significant predictors for the development of a clinically relevant PAF; a 0.1-U increase of L/E ratio decreased the odds of a PAF by 54%. ConclusionPancreatic CT enhancement pattern can accurately assess pancreatic fibrosis and is a powerful tool to predict the risk of developing a clinically relevant PAF following PD.

Preoperative Assessment of Pancreatic Fibrosis and Risk of Pancreatic Anastomotic Failure Following Pancreatoduodenectomy by Dual-Phase Computed Tomography

BACKGROUND: Delayed or decreased enhancement characteristics on computed tomography (CT) in patients with pancreatic fibrosis have been described. However, studies comparing clinical outcomes following pancreatoduodenectomy (PD) to preoperative CT enhancement characteristics are lacking. AIM: To study the ability of dual-phase CT to assess pancreatic fibrosis and to predict the risk of developing a pancreatic anastomotic failure (PAF) following PD. METHODS: Review of 157 consecutive patients with preoperative dualphase CT between 2004 and 2009. Pancreatic CT attenuation upstream from the tumor was measured in the pancreatic and hepatic imaging phases. The ratio of the mean CT attenuation value of the pancreas in the hepatic (late) and pancreatic (early) phase was calculated; L/E ratio and histological grade of pancreatic fibrosis assessed byMasson trichrome immunostaining were then correlated with the development of a clinically-relevant PAF and other clinical parameters. Results: A clinically-relevant PAF was found in 21 patients (13.4%) with a morbidity rate of 39.5%. No postoperative death was observed. The PAF group showed maximum enhancement in the pancreatic and washout in the hepatic CT phase, while the control group showed a delayed enhancement pattern. Degree of pancreatic fibrosis and L/E ratio were significantly lower for the PAF group than the control group (21.0 ± 17.9 vs. 40.4 ± 29.8; P < 0.0001 and 0.86 ± 0.14 vs. 1.09 ± 0.24; P < 0.0001); fewer PAF patients showed an atrophic histological pattern (14% vs. 39%; P = 0.046). The L/E ratio was positively correlated with pancreatic fibrosis. Pancreatic fibrosis and L/E ratio increased with larger duct size (P < 0.001), the presence of diabetes (P < 0.05), and the surgeon's assessment of pancreas firmness (P < 0.001). In multivariate analyses L/E ratio and BMI were significant predictors for the development of a clinically-relevant PAF; a 0.1 unit increase of L/E ratio decreased the odds of a PAF by 54%. CONCLUSIONS: Pancreatic CT enhancement characteristics quantified by the L/E ratio can accurately assess the histological grade of pancreatic fibrosis and are a powerful tool to predict the risk of developing a clinically-relevant PAF following PD. L/E ratio and pancreatic fibrosis are further associated with pancreatic texture, pancreatic duct size, and the presence of diabetes. This information may be helpful in guiding preand postoperative patient management.

Fifteen-Year Single Institution Experience With Surgical Treatment of Duodenal Carcinoma: A Comparison of Periampullary and Extra-Ampullary Duodenal Adenocarcinomas

BACKGROUND: Delayed or decreased enhancement characteristics on computed tomography (CT) in patients with pancreatic fibrosis have been described. However, studies comparing clinical outcomes following pancreatoduodenectomy (PD) to preoperative CT enhancement characteristics are lacking. AIM: To study the ability of dual-phase CT to assess pancreatic fibrosis and to predict the risk of developing a pancreatic anastomotic failure (PAF) following PD. METHODS: Review of 157 consecutive patients with preoperative dualphase CT between 2004 and 2009. Pancreatic CT attenuation upstream from the tumor was measured in the pancreatic and hepatic imaging phases. The ratio of the mean CT attenuation value of the pancreas in the hepatic (late) and pancreatic (early) phase was calculated; L/E ratio and histological grade of pancreatic fibrosis assessed byMasson trichrome immunostaining were then correlated with the development of a clinically-relevant PAF and other clinical parameters. Results: A clinically-relevant PAF was found in 21 patients (13.4%) with a morbidity rate of 39.5%. No postoperative death was observed. The PAF group showed maximum enhancement in the pancreatic and washout in the hepatic CT phase, while the control group showed a delayed enhancement pattern. Degree of pancreatic fibrosis and L/E ratio were significantly lower for the PAF group than the control group (21.0 ± 17.9 vs. 40.4 ± 29.8; P < 0.0001 and 0.86 ± 0.14 vs. 1.09 ± 0.24; P < 0.0001); fewer PAF patients showed an atrophic histological pattern (14% vs. 39%; P = 0.046). The L/E ratio was positively correlated with pancreatic fibrosis. Pancreatic fibrosis and L/E ratio increased with larger duct size (P < 0.001), the presence of diabetes (P < 0.05), and the surgeon's assessment of pancreas firmness (P < 0.001). In multivariate analyses L/E ratio and BMI were significant predictors for the development of a clinically-relevant PAF; a 0.1 unit increase of L/E ratio decreased the odds of a PAF by 54%. CONCLUSIONS: Pancreatic CT enhancement characteristics quantified by the L/E ratio can accurately assess the histological grade of pancreatic fibrosis and are a powerful tool to predict the risk of developing a clinically-relevant PAF following PD. L/E ratio and pancreatic fibrosis are further associated with pancreatic texture, pancreatic duct size, and the presence of diabetes. This information may be helpful in guiding preand postoperative patient management.

Comparison Between Delayed Enhancement Pattern of Cardiac Magnetic Resonance Imaging and Perfusion Abnormalities of 99mTC-sestamibi Scintigraphy in Cardiac Sarcoidosis

Background: Both cardiac magnetic resonance imaging (CMR) and myocardial perfusion imaging are useful in the detection of cardiac involvement in sarcoidosis. However, comparisons of delayed enhancement (DE) of CMR with myocardial perfusion abnormalities are not studied in cardiac sarcoidosis (CS). Methods: To compare the DE patterns and the incidence of perfusion abnormalities, we underwent CMR and 99mTc-sestamibi ECG-gated single photon emission computed tomography (SPECT) in 18 sarcoidosis patients with cardiac abnormalities.