Single Focal Lesion Research Articles

Quantitative MRI of a Cerebral Cryptococcoma Mouse Model for In Vivo Distinction between Different Cryptococcal Molecular Types.

The controversially discussed taxonomy of the Cryptococcus neoformans/Cryptococcus gattii species complex encompasses at least eight major molecular types. Cerebral cryptococcomas are a common manifestation of cryptococcal neurological disease. In this study, we compared neurotypical symptoms and differential neurovirulence induced by one representative isolate for each of the eight molecular types studied. We compared single focal lesions caused by the different isolates and evaluated the potential relationships between the fungal burden and properties obtained with quantitative magnetic resonance imaging (qMRI) techniques such as diffusion MRI, T2 relaxometry and magnetic resonance spectroscopy (MRS). We observed an inverse correlation between parametric data and lesion density, and we were able to monitor longitudinally biophysical properties of cryptococcomas induced by different molecular types. Because the MRI/MRS techniques are also clinically available, the same approach could be used to assess image-based biophysical properties that correlate with fungal cell density in lesions in patients to determine personalized treatments.

Assessment of efficacy and safety of irreversible electroporation versus TACE for treatment of difficult location hepatocellular carcinoma

IntroductionRadiofrequency ablation (RFA) and microwave ablation (MWA) are widely accepted as the established treatment options for patients diagnosed with early-stage hepatocellular carcinoma (HCC) who are deemed unfit for surgical procedures. However, the effective implementation of these techniques is hindered by various challenges, primarily associated with the precise targeting of tumors within the liver. The utilization of thermal ablative methods is not recommended for hepatocellular carcinoma (HCC) that is located near intestinal loops, bile ducts, or in eccentric positions. The unmet need for non-thermal methods in the treatment of hepatocellular carcinoma (HCC) was addressed following the introduction of irreversible electroporation (IRE) as an innovative approach.Aim of the workTo assess the efficacy, safety, and outcomes of IRE in the treatment of difficult-located HCC compared to transarterial chemoembolization (TACE).MethodsThis is a prospective study that included 24 patients with HCC who presented to the National Hepatology and Tropical Medicine Research Institute (NHTMRI) during the period from January 2017 to January 2020. Ten patients underwent IRE, while 14 patients underwent TACE.ResultsSixteen patients (66.7%) were males; eight patients were females (33.3%). Their median age was 60.5 years (48–70 years). Seventeen patients (70.8%) were Child–Pugh class A, while seven patients (29.2%) were Child–Pugh class B. All the study population had a single focal lesion; the mean size of the focal lesions was 2.94 ± 0.59 cm. The most frequent difficult locations of HCC were segment V focal lesions adjacent to both the common bile duct and portal vein in eight patients (33.3%) followed by lesions adjacent to the inferior vena cava in five patients (20%) followed by the subcapsular lesions in three patients (12.5%) and lesions adjacent to the right kidney in two patients (8.3%). Complete response (CR) was higher in the IRE group (80%) compared to the TACE group (50%). Clinical decompensation occurred in six patients in the IRE group (60%) and eight patients in the TACE group (57.1%) (P value 1). Recurrence occurred in five patients (50%) treated with IRE and in seven patients (50%) treated with TACE (P value 1). Within the IRE group, two patients (20%) remained alive; on the other hand, within the TACE group six patients (42.9%) remained alive by the end of the study (P value 0.388).ConclusionOur data suggest that IRE is an effective procedure in the treatment of difficult-located HCC in terms of complete response, fewer sessions, and fewer side effects as compared to TACE.

Single-stage autologous chondrocyte coimplantation on a hyaluronan scaffold for the treatment of knee cartilage lesions: a case series of 16 patients with clinical outcomes up to 5 years

IntroductionThe direct reimplantation of autologous primary articular chondrocytes in a single-stage procedure for knee cartilage lesions is a novel approach, yet to be extensively reported. This study aimed to evaluate the clinical outcomes and reinterventions over a 5-year period post-surgery. MethodsA prospective case series involving 16 patients (4 female, 12 male) with single or multiple focal knee cartilage lesions was conducted. The mean age at baseline was 36.8 (±11.5) years. The mean total lesion size was 4.5 (±2.3) cm2 Patients underwent surgery where articular chondrocytes and mononuclear bone marrow cells were isolated, mixed, and seeded onto a hyaluronan-based scaffold within the lesion. A structured physical therapy regimen was followed, and patients were assessed using Knee injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee (IKDC) Subjective questionnaires at various intervals. Overall, patient-reported outcomes improved over the first 3 years post-surgery, with slight declines thereafter. ResultsSignificant improvements over baseline were noted for various KOOS parameters and IKDC Subjective scores at different follow-up points. Reinterventions were required for two patients, one receiving intra-articular injections with mesenchymal stromal cells and another undergoing knee washout for septic arthritis while a meniscus implant was removed. Patient satisfaction at final follow-up was generally favorable. Despite a significant intraoperative cell isolation time of approximately 1.5 hours, the procedure demonstrated safety and efficacy, with an average of ±0.9 million articular chondrocytes obtained per case. ConclusionsThis study underscores the potential of coimplantation of intraoperatively isolated articular chondrocytes and bone marrow cells on a hyaluronan scaffold as a promising strategy for treating symptomatic knee cartilage lesions.

Clinical and morphological diagnostics of bening single focal lung lesions without necrotic changes

In recent decades, the problem of accidental detection by radiography or chest computer tomography of solitary focal formations smaller than 3 cm has become relevant. Although the primary task is to find out its benign or malignant nature as soon as possible, the clarification of the etiology of benign formations with non-neoplastic genesis retains an important clinical significance, in particular in cases of their infectious nature. The purpose of the study was to analyze the diagnostic significance of clinical and radiological data and morphological features of benign single focal lung lesions without necrotic changes, taking into account the final clinical diagnosis. The study group consisted of 42 patients with single benign focal lung lesions without necrosis. Among them there were 29 (69.0%) women and 13 (31.0%) men. Average age of the patients was (50.5±2.2) years. The total number of focal formations was 52. According to the number of focal formations, one patient was diagnosed with 1 formation in 34 cases, 2 formations in 6, and 3 formations in 2 cases. The dimensions of each of the formations did not exceed 30 mm. The most common diagnostic measures were direct biopsy at FBS, 10 (23.8%) cases; and transbronchial biopsy of lung under radiological control, 16 (38.1%) cases respectively. Among the operative interventions, lobe resection of the lung with a focus was mainly performed, in 16 (84.2%) cases. According to the results of the histological examination and taking into account the clinical and laboratory data, the following diagnoses were obtained, which corresponded to the final clinical diagnosis of the patients. A lung abscess was established in 4 (9.5%) cases; a chronic inflammatory process of a non-specific nature was diagnosed in 14 (33.3%) cases. Predominantly post-inflammatory changes and local pneumofibrosis were determined in 15 (35.7%) cases. Vascular malformation and pulmonary sarcoidosis were diagnosed once. In another 7 (16.7%) cases, the final clinical diagnosis was based on clinical and laboratory data and patient supervision - in 2 observations, the final diagnosis of chronic non-specific pulmonary disease was made; and in 5 cases, the nature of single focal pulmonary formations was not established. The most numerous subgroups were cases with a chronic nonspecific inflammatory process and with limited post-inflammatory changes (in total, they amounted to 69.0%), so the clinical and radiological indicators of these subgroups were analyzed more detail. Overall clinical data did not differ significantly between both subgroups. Females predominated in the group with post-inflammatory changes. The number of focal lesions in both lungs was equal; the upper lobes were more often affected. The average size of foci was significantly larger in patients with a chronic inflammatory process and was 22.2 mm compared to 16.3 mm in the subgroup with post-inflammatory changes (p<0.05). Single foci with minimal destructive changes were observed only in the subgroup with a chronic inflammatory process. As a result of the research, such findings were obtained. Among benign single non-necrotized focal pulmonary lesions chronic non-specific inflammatory process and post-inflammatory fibrotic changes, including focal pneumofibrosis, predominate in etiology. In our study, they accounted for 69% of all cases. According to the main radiological indicators (localization, size, shape, characteristics of the internal contents) it is impossible correct determination of the benign nature of non-necrotized focal lung lesions in the vast majority of cases. Histological examination of tissue of focal lesions not only determines benign or malignant nature of the formations, but also, in the case of their benign nature, allows clarify their etiology in most cases (83.3%). Keywords: benign non-necrotized focal lung lesions, X-ray indicators, histological diagnostics.

Assessment of clinico-epidemiological profile of Hepatocellular carcinoma in the last two decades

BackgroundHepatocellular carcinoma represents 85%—90% of primary liver tumors; it represents the 2nd leading cause of cancer-related death all over the world. There is a growing incidence of HCC worldwide and similarly, the incidence of HCC has almost doubled over the last decade in Egypt.Aim of the workTo assess clinico-epidemiological character of HCC in the last two decades and to compare between the first and second decade regarding these characters.Patients and methodsThis retrospective study included 497 HCC patients’ data collected from Clinical Oncology and Nuclear Medicine Department from 1999 to 2019, HCC patients were classified into 1st decade (from 1999 to 2009) and 2nd decade (2010 – 2019). Diagnosis of HCC was based on clinical, laboratory, (AFP), and radiological examinations (The abdominal US and triphasic CT scan).ResultsThe study revealed that the average age of HCC cases was 57 years, the majority of these were males (88%), residents in rural areas (70%), about one-fourth of them, were smokers (26.4%), DM was present in 14% of these while only 7% were hypertension. Thirty presents (30%) of them were represented by ascites and (20%) by hepatic encephalopathy of different grades. The majority of HCC patients (92.2%) have HCV Abs positive. HBS Ag was positive in 2.4% while mixed infection (HCV Abs + ve and HBS Ag + ve) was in 2% of patients only. The median level of AFP was 300 ng/ml.The severity of underlying chronic liver disease was assessed by the Child–Pugh score the mean score was 7.5 (from 6–11) and the MELD score (the mean score was 18.8 (from 6–29).Regarding tumor characteristics, HCC mass was located in the Right lobe of the liver in (63.8%), in the left lobe in (26.6%) and both lobes were affected in 9.6%. A single focal hepatic lesion was detected in about 60% of patients, 3 focal lesions in about 20%, and two focal lesions or multifocal HCC in the remaining percent. The median size of the largest tumor’s diameter was 5 cm by the US and 5.3 cm by the triphasic CT. PVT, vascular invasion, LN, and distant metastasis were detected in (35.6%), (40%), (40%) and (54%) of patients respectively. In less than one-third of HCC cases, the tumors were within Milan criteria (30%).ConclusionThe 1st decade showed a significantly higher frequency of patients presented with marked splenomegaly and splenectomy, while the second decade showed a significantly higher frequency in patients who reside in rural areas. Higher frequency of DM, advanced hepatic encephalopathy grade III/ IV, and unfortunately more aggressive tumors with PVT, vascular invasion, LN metastasis, and distant metastasis were detected in the 2nd decade.

Genetic profile of MIF single nucleotide polymorphism (rs755622 G>C) in hepatocellular carcinoma among Egyptian patients.

To evaluate the role of MIF gene polymorphism rs755622 G>C in occurrence and progression of hepatocellular carcinoma (HCC) among a cohort of Egyptian patients. This case-control study was conducted on 50 patients with HCC after chronic viral hepatitis and 50 healthy volunteers, recruited between July 2021 and January 2022. All patients with HCC were evaluated for severity of liver disease using a Child-Pugh score, and TNM and BCLC scoring systems. MIF 173 G>C (rs755622) single nucleotide polymorphism was performed for all participants by polymerase chain reaction using restriction fragment length polymorphism technique (RFLP-PCR). Overall results showed significantly higher frequencies of GG (wild homozygous genotype) and mutant heterozygous genotype GC and G allele (OR = 6.303, 95% CI: 3.374-11.775) among patients with HCC compared to the control group (p = 0.001) for all. Also, significantly higher frequency of genotype GG was detected among patients with advanced Child scores (B and C) (p = 0.039) and TNM stages (III and IV) (p = 0.013). There was significantly higher frequency of the G allele among patients with multiple hepatic focal lesions compared to those with a single focal lesion (p = 0.01). An obvious role of MIF (rs755622) gene polymorphism could have an important role in susceptibility and progression of HCC among patients with chronic viral hepatitis induced liver cirrhosis.

How to Treat Isolated Leptomeningeal Relapse of Multiple Myeloma 11 Years after Autologous Stem Cell Transplantation (ASCT)

Post transplant relapse of Multiple Myeloma (MM) in the central nervous system (CNS) is rare and it is almost always associated with systematic relapse and in most instances, shortly after initial treatment. We did not encounter reports of relapse isolated to the CNS ten years post-transplant. In October 2009, a 49-year-old male presented with an IgG lambda MM, ISS II. He was treated with Bortezomib/Dexamethasone, autologous PBSCT, followed by two years maintenance with Lenalidomide, attaining stringent CR, confirmed by PET/CT. He discontinued follow up and returned after 11y/8m progression free survival, in June 2021 with paraplegia due to cauda equina syndrome. NMR consistent with leptomeningeal infiltration, single focal intramedullary lesion at L1 level without bone affectation. No MM defining criteria (CRAB). Normal levels of serum Immunoglobulins (IGs), serum and urine immunofixation, and serum free light chains. Flow cytometry negative in bone marrow. Spinal tap was unsuccessful and through an Ommaya reservoir, that was placed after NMR showed evidence of cranial leptomeningeal involvement, CSF showed infiltration by countless malignant plasma cells. Patient received immediate conformational radiotherapy and biweekly IT methotrexate and hydrocortisone. A month later his course was complicated by left leg proximal deep vein thrombosis and pulmonary embolism which was treated with Apixaban. Given the rarity of this type of relapse, we questioned the appropriateness of the treatment and searched the literature with respect to the accessibility of the CNS by the different novel drugs used to treat MM in order to determine the most effective strategy. In addition to corticosteroids, there is clinical evidence that thalidomide crosses the blood-brain barrier (BBB), in murine models pomalidomide also has good penetration into the CNS. Both have a penetration of 30 to 40% into the CSF. Among proteasome inhibitors, only marizomib has been observed to cross the BBB in a murine model, while bortezomib does not. With respect to anti CD38 monoclonal antibodies, mass spectrometry at 12, 15, and 19 days after daratumumab infusion showed antibody levels in CSF 71 times less than in serum on the three sample days. It is not known if weekly doses of daratumumab could attain therapeutic levels in CSF. We found only 14 cases of isolated CNS relapse in patients with MM treated with ASCT with a median interval between transplant and relapse of 3 months (0.5-96m), with only one reported relapse 7.5 years after autologous transplant and the median overall survival was only 3 months. Two cases died in less than a month and only one case survived for a year after the CNS relapse.To date, our patient has received 12 cycles of Pomalidomide/dexamethasone with progressive improvement, now he is able to carry on his life unassisted and there is no evidence of MM relapse anywhere. The rarity of this case scenario highlights the lack of knowledge regarding the best approach to CNS MM relapse. There is no evidence of the effectiveness of methotrexate and Ara C, in MM, and no novel drug can be instilled into the CSF. We conclude that the systemic use of pomalidomide and dexamethasone should be the best approach of MM isolated CNS relapse. Further investigations will clarify if other novel drugs are active in this context.

Macroscopic Synovial Inflammation Correlates with Symptoms and Cartilage Lesions in Patients Undergoing Arthroscopic Partial Meniscectomy: A Clinical Study.

Background: The aim of the study was to examine the relationship among patients’ characteristics, intraoperative pathology and pre/post-operative symptoms in a cohort of patients undergoing arthroscopic partial meniscectomy for symptomatic meniscal tears. Methods: Clinical data were collected (age, sex, body mass index, time to surgery, trauma). Intraoperative cartilage pathology was assessed with Outerbridge score. Meniscal tears were graded with the ISAKOS classification. Synovial inflammation was scored using the Macro-score. Patient symptoms were assessed pre/post-operatively using the KOOS instrument. Results: In the series of 109 patients (median age 47 years), 50% of the meniscal tears were traumatic; 85% of patients showed mild to moderate synovitis; 52 (47.7%) patients had multiple cartilage defects and 31 (28.4%) exhibited a single focal chondral lesion. Outerbridge scores significantly correlated with patient age, BMI and synovial inflammation. There was a correlation between severity of chondral pathology and high-grade synovial hyperplasia. Pre-operative KOOS correlated with BMI, meniscal degenerative changes and symptom duration. Obesity, time to surgery, presence of high-grade synovial hyperplasia and high-grade cartilage lesions were independent predictors of worse post-operative pain and function. Conclusion: We demonstrated that pre-operative symptoms and post-operative outcomes correlate with synovitis severity and cartilage pathology, particularly in old and obese patients that underwent arthroscopic partial meniscectomy. Importantly, patients with a degenerative meniscal pattern and with longer time to surgery experienced more severe cartilage damage and, consequentially, pain and dysfunction. These findings are fundamental to identify patients suitable for earlier interventions.

Microwave ablation versus Radiofrequency ablation in the management of Hepatocellular carcinoma

Background: Different loco-regional therapies have been progressed for irresectable liver tumors to achieve local tumor control. Examples of loco-regional therapies are different thermal ablation therapies such as microwave ablation, and radiofrequency ablation. Objectives: We aimed to evaluate treatment safety, efficacy, and complications related to radio-frequency ablation (RFA) in comparison with percutaneous microwave (MW) ablation for the management of HCC. Patients and Methods: 100 patients presented with liver cirrhosis and HCC proved by imaging ultrasonography and triphasic CT. Patients were assigned into two main comparison groups: Group 1: patients with single or multiple hepatic focal lesions (size up to 4cm) who received RFA. Group 2: patients with single or multiple hepatic focal lesions (size up to 4cm) who received MWA. Complete blood count, liver function tests, and AFP were measured for all subjects. Results: In All 100 patients; the assessment number of the hepatic focal lesion was done by abdominal ultrasonography and triphasic CT 93% of patients had a single focal lesion with a median size of 2.3cm. Group (1): (who were candidates for RFA) showed statistically significant higher values as regard (ALT) (p-value =0.091) compared to group (2): (who were candidates for MWA). There were no statistical differences between both groups as regard Total Bilirubin and serum AFP. The microwave ablation group was statistically significant as regard ablation success, shorter time, and shorter ablation than the radiofrequency ablation group (p-value =0.000). Conclusions: RFA and MWA are good ablative techniques. MWA showed more superiority than RFA in the overall outcome.

Detecting Imaging For Neoplastic Liver Masses in Hepatic Patients Who Received Direct Acting Antiviral Drugs

Background: Hepatocellular carcinoma makes up 75%-85% of all primary liver cancers and is the fourth most common cause of cancer related death worldwide. The aim of this study was to screen for hepatocellular carcinoma in hepatic patients who received direct acting antiviral drugs using different imaging modalities. Methods: This was a cross sectional study included 50 patients who were hepatic and received Direct Acting Antiviral '' DAA'' and were carried out at radiology department in Elobour Hospital for Health Insurance after obtaining written informed consent from all patients. Results: There were 31(62%) male, 19(38%) female, the mean age 52.28 years old with range (39-65), 35(70%) urban, 15(30%) rural. There were (70%) with duration of illness ≤ 5 years, (30%) with > 5 years, (100%) with DAA, (90%) easy to treat, (10%) difficult to treat. There were 35(70%) with average liver, 14(28%) with shrunken liver, 1(2%) with enlarged liver, 13(26%) with Bright pattern, 34(68%) with cirrhotic, 3(6%) with coarse bright, the mean P.V diameter 14.68(± 2.51 SD) with range (9-17).There were (100%) with Single focal lesion in RT lobe, the mean size 4.47with range (3.6-5.6), (33.3%) Isochoric, (33.3%) with Hypo echoic, (33.3%) with Hyper echoic, (66.7%) with malignancy. There were 3(100%) with typical CT enhancement, 1(33.3%) with P.V thrombosis. There was no one with Affection on liver vascular, no one with intrahepatic biliary radicles, no one with L.N in porta hepatis. Conclusion: Based on our findings, we recommend for close imaging evaluations after DAA in cirrhotic patients.

Contrast-Enhanced Ultrasound LI-RADS LR-5 in Hepatic Tuberculosis: Case Report and Literature Review of Imaging Features

Background: The liver is involved in disseminated tuberculosis in more than 80% of cases while primary liver involvement is rare, representing <1% of all cases. Hepatic tuberculosis (TB) can be treated by conventional anti-TB therapy; however, diagnosing this disease remains a challenge. The diagnosis might be particularly difficult in patients with a single liver lesion that could be misdiagnosed as a tumor or other focal liver lesions. Although computed tomography (CT) and magnetic resonance imaging (MRI) findings have been described, there is a paucity of literature on contrast-enhanced ultrasound (CEUS) features of hepatic TB. Case Summary: herein, we describe a case of a patient with tuberculous lymphadenopathy and chronic Hepatitis C Virus (HCV)-related liver disease who developed a single macronodular hepatic TB lesion. Due to the finding of a hepatocellular carcinoma (HCC) highly suggestive CEUS pattern, specifically a LR5 category according to the Liver Imaging Reporting and Data System (LI-RADS), and a good response to antitubercular therapy, a non-invasive diagnosis of HCC was made, and the patient underwent liver resection. We also review the published literature on imaging features of hepatic TB and discuss the diagnostic challenge represented by hepatic TB when occurs as a single focal liver lesion. Conclusions: this report shows for the first time that the CEUS pattern of hepatic TB might be misinterpreted as HCC and specific imaging features are lacking. Personal history and epidemiological data are mandatory in interpreting CEUS findings of a focal liver lesion even when the imaging pattern is highly suggestive of HCC.

Single, unilateral halo sign in COVID-19 pneumonia

•Radiologists should know the atypical CT findings of COVID-19 pneumonia as well as the typical ones•A single focal halo-sign lesion has never been described before as manifestation of COVID-19 pneumonia•CT halo-sign could represent a consequence of thrombotic damage of pulmonary microcirculation•In the setting of asymptomatic patients, unilateral single halo-sign should alert to the possibility of COVID-19 pneumonia We read with great interest the article by McLaren et al., recently published in Clinical Imaging.[1]McLaren T.A. Gruden J.F. Green D.B. The Bullseye sign: a variant of the reverse halo sign in COVID-19 pneumonia.Clin Imaging. 2020; 68: 191-196https://doi.org/10.1016/j.clinimag.2020.07.024Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar We agree on the importance of describing atypical CT findings in COVID-19 to better and more comprehensively understand this newly emerged disease and on the effort of correlating pathologic alterations (as diffuse alveolar damage, organizing pneumonia, microthrombi and hemorrhagic infarcts) with CT findings. We think CT could be a useful tool to enlighten its pathophysiology through the study of the abnormalities that we can observe with High Resolution Chest CT (HRCT) at a very high anatomical detail. McLaren et al. described the bullseye sign, a variant of the reverse halo sign, as an atypical manifestation of COVID-19 pneumonia. Similarly, Poerio et al.[2]Poerio A. Sartoni M. Lazzari G. et al.Halo, reversed halo, or both? Atypical computed tomography manifestations of coronavirus disease (COVID-19) pneumonia: the “double halo sign”.Korean J Radiol. 2020; 21: 1161-1164https://doi.org/10.3348/kjr.2020.0687Crossref PubMed Scopus (7) Google Scholar described a combination of multiple and bilateral halo sign, reverse halo sign and double halo sign as main CT findings in a 55 year-old woman with COVID-19. Both authors explained these atypical findings as manifestations of organizing pneumonia (reverse halo sign) and extensive thrombotic damage of pulmonary microcirculation (halo sign and double halo sign). At our center, a reference hospital for COVID-19 in Northern Italy, we collected a large series of chest X-ray and CT in symptomatic patients with suspicion and/or confirmation of SARS-CoV-2 infection. Among these, we believe it could be useful to describe the case of a 42 year-old male nurse presented with a 2 days history of arthromyalgia and an isolated episode of fever up to 38 °C (100.4 °F). At admission, laboratory studies showed leucopenia and elevated C-reactive protein (15.2 mg/L); a positive rapid antigen test confirmed SARS-CoV-2 infection. Chest x-ray showed no alterations, whereas a chest CT showed, as single finding, a rounded consolidation surrounded by ground-glass opacity (halo sign) in the left lower lobe (Fig. 1). The patient was then discharged to quarantine at home. Asymptomatic or paucisymptomatic COVID-19 patients might have normal chest CT[3]Kwee T.C. Kwee R.M. Chest CT in COVID-19: what the radiologist needs to know.RadioGraphics. 2020; 40: 1848-1865https://doi.org/10.1148/rg.2020200159Crossref PubMed Scopus (160) Google Scholar; in case of lung abnormalities, CT findings are frequently unilateral (58.6%).[4]Heng M. Xiong R. He R. et al.CT imaging and clinical course of asymptomatic cases with COVID-19 pneumonia at admission in Wuhan, China.J Infect. 2020; 81: e33-e39https://doi.org/10.1016/j.jinf.2020.04.004Abstract Full Text Full Text PDF Scopus (169) Google Scholar Moreover, Shi et al. reported that the predominant pattern in early stages is characterized by unilateral, although multifocal GGO.5.Shi H. Han X. Jiang N. et al.Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study.Lancet Infect Dis. 2020; 20: 425e34https://doi.org/10.1016/S1473-3099(20)30086-4Abstract Full Text Full Text PDF Scopus (2238) Google Scholar To the best of our knowledge, a single focal halo-sign lesion has never been described before as manifestation of COVID-19 pneumonia. Halo sign has rather been observed, in the context of more typical CT findings, as multiple and bilateral lesions, sometimes associated with reverse CT halo sign.[6]Shaghaghi S. Daskareh M. Irannejad M. et al.Target-shaped combined halo and reversed-halo sign, an atypical chest CT finding in COVID-19.Clin Imaging. 2020; 69: 72-74https://doi.org/10.1016/j.clinimag.2020.06.038Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Halo-sign is non-specific and histopathologically usually represents alveolar edema and hemorrhage.[7]Pinto P.S. The CT halo sign.Radiology. 2004; 230: 109-110Crossref PubMed Scopus (72) Google Scholar Although different from the bullseye sign, the lesion we presented showed connection to the vascular system too, as suggested from a pulmonary vein branch reaching it. Thus, it is likely that in SARS-Cov-2 infection halo sign represent a consequence of thrombotic damage of pulmonary microcirculation. In conclusion, we believe that radiologists should know the atypical CT findings of COVID-19 pneumonia as well as the typical ones. In the setting of asymptomatic patients and in case of short time between symptom onset and hospital admission, the presence of unilateral single halo-sign should alert to the possibility of COVID-19 pneumonia. No conflict of interest or industry support for the two authors.

HCC-Mark: a simple non-invasive model based on routine parameters for predicting hepatitis C virus related hepatocellular carcinoma

ABSTRACT Background Early detection of hepatocellular carcinoma (HCC) is crucial in providing more effective therapies. As routine laboratory variables are readily accessible, this study aimed to develop a simple non-invasive model for predicting hepatocellular cancer. Methods Two groups of patients were recruited: an estimation group (n = 300) and a validation group (n = 625). Each comprised two categories: hepatocellular cancer and liver cirrhosis. Logistic regression analyses and receiver operating characteristic (ROC) curves were used to develop and validate the HCC-Mark model comprising AFP, high-sensitivity C-reactive protein, albumin and platelet count. This model was tested in cancer patients classified by the Barcelona Clinic Liver Cancer (BCLC), Cancer of Liver Italian Program (CLIP) and Okuda systems, and was compared with other non-invasive models for predicting hepatocellular cancer. Results HCC-Mark produced a ROC AUC of 0.89 (95% CI 0.85–0.90) for discriminating hepatocellular carcinoma from liver cirrhosis in the estimation group and 0.90 (0.86–0.90) in the validation group (both p < 0.0001). This AUC exceeded all other models, that had AUCs from 0.41 to 0.81. AUCs of HCC-Mark for discriminating patients with a single focal lesion, absent macrovascular invasion, tumour size <2 cm, BCLC (0-A), CLIP (0–1) and Okuda (stage Ι) from cirrhotic patients were 0.88 (0.85–0.90), 0.87 (0.85–0.89), 0.89 (0.85–0.93), 0.87 (0.84–0.89), 0.85 (0.82–0.87) and 0.86 (0.83–0.89), respectively (all p < 0.0001). Conclusion HCC-Mark is an accurate and validated model for the detection of hepatocellular cancer and certain of its clinical features.

Perampanel as add-on therapy in epilepsies with known etiology: A single center experience with long-term follow-up.

We report a retrospective monocentric study performed on 63 patients affected by epilepsy with known etiology, receiving perampanel as add-on therapy with at least 12-month follow-up. The purpose of our study was to evaluate efficacy and tolerability of perampanel in this group of epilepsies. Patients were classified into 2 groups based on the presence/absence of a single focal brain lesion on MRI, as epilepsy etiology: 48 subjects were affected by focal lesional epilepsy and 15 by non-focal lesional epilepsy. The retention rate was 76.2% and 53.9% at 12 and 24months respectively. At 12months, at least 40% of patients resulted responders, with a significant reduction in seizure frequency (p=0.01), confirmed at 24months. Considering epilepsy etiology, we found a better PER response in patients with focal lesional epilepsy. A significant correlation was observed between responderrates and EEG pattern. Only 30% of patients reported mild-moderate adverse events. Efficacy and tolerability of PER, in our study, are in line with the results reported in other real-world studies. Our data suggest the possibility of better PER response in patients with focal brain lesions, which indicates that this drug could be a therapeutic option in this population.

Laparoscopic liver resection for hepatocellular carcinoma: a single-center experience in upper egypt

Background Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide. Liver transplantation is an effective therapy for HCC but cannot be done in all HCC cases. Hepatic resection is the first-line therapy for HCC in compensated cirrhosis with proven cure. Laparoscopic liver resection (LLR) of HCC had a lower frequency of postoperative complications than open approach. Aim The aim was to determine the feasibility, safety, and outcome of LLR for HCC in a single center. Patients and methods This study was done on patients with HCC who underwent laparoscopic resection during 2 years. LLR was decided by the surgical team based on the location of the tumor and its size in imaging. All cases were cirrhotic Child–Pugh class A with a single focal lesion. Operative time, blood loss volume, hospital stay, and postoperative complications were reported. Results This study included 20 HCC cases with a mean age 55.6±9.1 years. Of them, 60% were male. The mean size of focal lesion was 3.9±0.8 cm. Wedge resection was done in 65% of cases. Left lateral anatomical resection was done in 35%. Duration of operation ranged from 70 to 120 min. Bleeding occurred in one case only and was converted to open (5%). Hospital stays ranged from 2 to 4 days. Postoperative ascites occurred in one (5%) case. No short-term mortality was seen. Conclusion Laparoscopic minor hepatectomy is an acceptable approach in selected cases of HCC with decreased blood loss, shorter stay in the hospital, and less complications.

Disconnection somewhere down the line: Multivariate lesion-symptom mapping of the line bisection error

Line Bisection is a simple task frequently used in stroke patients to diagnose disorders of spatial perception characterized by a directional bisection bias to the ipsilesional side. However, previous anatomical and behavioural findings are contradictory, and the diagnostic validity of the line bisection task has been challenged. We hereby aimed to re-analyse the anatomical basis of pathological line bisection by using multivariate lesion-symptom mapping and disconnection-symptom mapping based on support vector regression in a sample of 163 right hemispheric acute stroke patients. In line with some previous studies, we observed that pathological line bisection was related to more than a single focal lesion location. Cortical damage primarily to right parietal areas, particularly the inferior parietal lobe, including the angular gyrus, as well as damage to the right basal ganglia contributed to the pathology. In contrast to some previous studies, an involvement of frontal cortical brain areas in the line bisection task was not observed. Subcortically, damage to the right superior longitudinal fasciculus (I, II and III) and arcuate fasciculus as well as the internal capsule was associated with line bisection errors. Moreover, white matter damage of interhemispheric fibre bundles, such as the anterior commissure and posterior parts of the corpus callosum projecting into the left hemisphere, was predictive of pathological deviation in the line bisection task.

Role of abbreviated MRI protocol for screening of HCC in HCV related cirrhotic patients prior to direct-acting antiviral treatment

BackgroundChronic HCV infection is a global health problem causing progressive hepatic fibrosis, cirrhosis, and ultimately hepatocellular carcinoma (HCC). Recent advantage of direct-acting antiviral drugs (DAA) with a high sustained virologic response (SVR) reduces overall HCV-related morbidity and mortality, yet recent studies report a high recurrence rate of HCC after DAA; this calls availability of a reliable screening method to properly exclude HCC before DAA treatment.The primary objective of our cohort study was to assess the feasibility of an abbreviated MRI protocol as a screening tool for the detection of hepatic focal lesions/early HCC in patients with HCV-related liver cirrhosis.The study included 41 patients with HCV-related cirrhosis candidates to DAA therapy. All patients underwent routine screening for HCC by combined abdominal ultrasound and serum alfa-fetoprotein. An abbreviated MRI protocol (Abr-MR) including combined T2-weighted image and diffusion-weighted imaging (DWI) followed by dynamic contrast-enhanced MRI (CE-MRI) was performed for all subjects, assessing for presence and characterization of focal lesions.ResultsFor all included 41patients, no elevation of the alpha-fetoprotein was shown. Ultrasound detected a single focal lesion in one patient. Abbreviated MR demonstrated 15 focal lesions; for detected lesions, 1 lesion shows “shine though” and the rest showing moderate and high degrees of restriction. CE-MRI characterized lesions as 1 lesion = LIRADS-1, 3 lesions = LR-M, and 11 lesions = LR-5.The standard screening using combined ultrasound and alpha-fetoprotein had sensitivity, specificity, PPV, and NPV of 6.6 % (95% CI = 0.0034–0.29), 100% (95% CI = 0.89–1.000), 100% (95% CI = 0.051–1.000), and 68.8% (95% CI = 0.54–0.80). Abr-MR protocol showed sensitivity, specificity, PPV, and NPV of 100% for all parameters (95% CI = 0.79–1.000, 0.89–1.000, 0.79–1.000, and 0.89–1.000 respectively).ConclusionIn our study, we demonstrate the superiority of a proposed cost-effective Abr-MR protocol in the detection of hepatic focal lesions and small-sized HCC compared to routine screening using alpha-fetoprotein and ultrasound in HCV-related liver cirrhosis.

Prostate penile metastasis: Incidence and imaging pattern on 68 Ga-PSMA PET/CT.

Prostate cancer commonly metastasises to bone and regional lymphatics and more rarely to locations such as the brain, skin and penis. Gallium-68 prostate-specific membrane antigen (68 Ga-PSMA) positron emission tomography/computed tomography (PET/CT) has widely become the routine imaging modality for prostate cancer staging and re-staging in Australia. The aim of this study was to retrospectively review all 68 Ga-PSMA PET/CT examinations performed to date at our institution to determine the frequency of penile metastases. A total of 4860 68 Ga-PSMA PET/CT examinations were performed between 16/07/2014 and 31/10/2019. Radiology reports for each examination were filtered to identify those with the words 'penis' or 'penile'. Once identified, relevant reports and images were individually reviewed to confirm the presence of a PSMA-avid penile lesion. The incidence of penile metastasis of prostate cancer observed in this study was 0.1% with six examinations identified as having PSMA-avid penile lesions in five prostate cancer patients (age range: 71-88years). The patients had a 1-8year history of prostate cancer with varying severity of disease. Appearance of PSMA-avidity varied between single focal lesion, multiple focal lesions and diffuselesion. An incidence of 0.1% in our study confirms the rarity of penile metastases of prostate cancer. Although rare, identification of prostate cancer penile metastases is important for appropriate treatment management and symptom-relief.

Long-term scintigraphic and clinical follow up in patients with differentiated thyroid cancer and iodine avid bone metastases.

The aim of this study was to evaluate the long-term overall therapy outcomes and clinicopathological risk factors in patients with differentiated thyroid cancer (DTC) and iodine avid bone metastases. Our study included 93 patients [female to male ratio (2:1)]. All patients were subjected to clinical examination, laboratory assessment, I-131 whole body scan, and neck ultrasound. Iodine avid metastases were treated with successive radioactive iodine-131 (RAI-131) doses. The overall response was defined as complete response (CR), incomplete response (IR) [partial response (PR) and stable disease (SD)], and progressive disease (PD). Fifty-four patients had follicular carcinoma and 39 with papillary type. Isolated bone metastases, bone and lung metastases, and multi-organ metastases were found in 45, 34, and 14 patients, respectively. The overall CR, PR, SD, and PD were found in 8.6%, 28%, 46.2%, and 17.2% patients, respectively. Adjunctive radiotherapy resulted in more CR, IR, and low PD rates compared to RAI-131 therapy (9.0%, 78.3%, 12.7% vs. 7.9%, 56.8%, and 23.7%, respectively) (P = 0.03). The overall survival rate was 88.2% and median follow-up period was 123 months. Female patients, papillary carcinoma, and single focal lesion had better overall response rate. Males, extrathyroidal extension, vascular invasion, and lymph nodes metastases had increased PD and decreased global response rates. Despite of low CR rate (8.6%), most patients with DTC and iodine avid bone metastases had SD (46.2%) and long lived (88.2%). Adjunctive radiotherapy reduced PD and improved outcome. Males, extra thyroid extension and vascular invasion were bad prognostic factors.

Circulating hematopoietic stem cells, endothelial progenitor cells and cancer stem cells in hepatocellular carcinoma patients: contribution to diagnosis and prognosis

Background and aim: Circulating hematopoietic stem cells (HSCs), circulating endothelial progenitor cells (EPCs) and cancer stem cells (CSCs) contribute to tumor development and progression and can predict patient outcome. The aim of this study was to investigate the frequency of circulating HSCs, EPCs and CSCs in the peripheral blood of patients with hepatocellular carcinoma (HCC) and to explore their potential prognostic significance for HCC patients.Methods: The study included 30 HCC patients and 20 healthy controls. The HSCs and EPCs were enumerated with CD45, CD34, CD133, CD144 markers, while CSCs were enumerated with CD45, CD44, CD133 markers using flow cytometry.Results: The mean percentages of circulating HSCs were significantly lower in HCC patients than the controls (p = .001), whereas the mean percentages of EPCs within the HSCs subpopulation were significantly higher in the HCC patients than the controls (p = .002). The absolute count of CSCs within 100,000 peripheral blood mononuclear cells was 23.5 ± 3.4 in the HCC patients. Also, the mean percentages of circulating HSCs, EPCs and the number of CSCs were significantly increased in patients with multiple hepatic focal lesions than in patients with a single hepatic focal lesion. Both circulating HSCs and EPCs showed significant positive correlation with the level of AFP and with the numbers of CSCs. In the meantime, the numbers of CSCs revealed significant direct correlation with ALT, AST and AFP levels. The one-year overall survival (OS) of the patients was 77.5%. High levels of CSCs, HSCs and EPCs at diagnosis were all associated with worse outcome for the HCC patients.Conclusions: Significant changes in the levels of the circulating HSCs, EPCs and CSCs occur in HCC. These changes help the diagnosis and the prediction of HCC outcome, as higher levels of these cells are associated with worse OS.