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Lymphorrhea is a rare but potentially severe complication that occurs after various surgical pro cedures. Untreated lymphorrhea may lead to wound dehiscence, infection, and prolonged hospi tal stay. Currently, there is no standard effective treatment. Early management usually includes leg elevation, drainage, and pressure dressing. However, these methods are associated with pro longed recovery and high recurrence rates. We report a case of lymphorrhea from a calf wound after endoscopic great saphenous vein (GSV) harvesting for coronary artery bypass grafting (CABG). The patient presented with intractable oozing from the postoperative wound on the right calf. Lymphorrhea persisted for 6 weeks despite negative-pressure wound therapy with a long-acting somatostatin. We performed unilateral pedal lymphangiography that confirmed wound lymphorrhea, followed by glue embolization. No recurrence was observed after 8 months of follow-up. This case report demonstrates the successful use of lymphangiography with glue embolization in the control of lymphorrhea after GSV harvesting for CABG.

The objective was to assess which image-based criteria can be best accurately determined at MDCT and which results in least overtreatment. A total of 110 consecutive patients, who underwent curative surgery for colon cancer, were included in this retrospective study. Five radiologists independently assessed the longitudinal diameter of cancer as well as T- and N-categories. The five image-based criteria (T3cd/T4, T3/T4, T3/T4 or N+, T3cd/T4 or N2, and T3/T4 with ≥ 4 cm) were evaluated in terms of diagnostic accuracy, interreader agreement, and overtreatment risk using pooled receiver-operating curve and Fleiss kappa analyses. Pathologic high-risk stage II or III was used as a reference standard for assessment of overtreatment risk. The diagnostic accuracy of multireaders was in the acceptable range (pooled area under curve (AUC): 0.751–0.829). T3/T4 showed the highest AUC (0.829) in terms of diagnostic accuracy. T3/T4 with ≥ 4 cm showed the highest kappa value (κ = 0.695) followed by T3/T4 (κ = 0.623), indicating substantial agreement. The other three criteria revealed moderate agreement (κ = 0.558–0.577). In terms of overtreatment ratio, T3cd/T4 and T3cd/T4 or N2 showed relatively lower ratios (T3cd/T4, 2.2%; T3cd/T4 or N2, 2.9%), whereas T3/T4 and T3/T4 or N+ revealed higher ratios (T3/T4, 8.7%; T3/T4 or N+, 9.5%). T3/T4 was the best criterion in terms of diagnostic accuracy. However, in terms of interreader agreement and overtreatment risk, T3/T4 with ≥ 4 cm and T3cd/T4 were better as potential image-based criteria of neoadjuvant chemotherapy for colon cancer.

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract (GIT). In fewer than 5% of cases, GIST originates primarily from outside the GIT. The occurrence of GIST originating from the pancreas is rare. Sometimes, neuroendocrine tumors should be differentiated from GISTs because of their hyperenhancing nature in radiologic images. We report a case of GIST arising in the pancreas that was confirmed by surgical resection.

To analyze relevant metrics involved in Denali Vena Cava Filter placement via different venous access sites.Patients with Denali filters inserted between March 2017 and February 2018 were retrospectively analyzed. Pre-procedural and pre-retrieval computed tomography (CT) were reviewed. We compared inferior vena cava (IVC) diameter, filter tilt angle, filter tip IVC wall abutment, fluoroscopy time, and retrieval outcomes by venous access site. Filter tip abutment/limb penetration and procedure-related complications were investigated.Seventy-eight patients had successfully-placed Denali filters. Seventy-one of 78 (91%) patients had both pre-procedural and pre-retrieval CT. The majority (35 [49%]) were placed via the right femoral vein (left femoral vein: 22 [31%]; right internal jugular vein: 14 [20%]). The jugular approach involved a longer fluoroscopy time (mean 117 ± 37 s [s]) than the right and left femoral approaches (mean 64 ± 21 s, mean 67 ± 15 s, respectively [p 0.05]). Filter tilt and filter tip abutment were not significantly different between the 3 access routes. Filter tip abutment and limb penetration were observed in 8/71 (11%) and 2/71 (3%) patients, respectively. Filter retrieval was attempted in 68 of 78 (87%) cases, and all filters were successfully retrieved. One filter arm fractured during advanced retrieval; no other procedure related complications were recorded.Both femoral venous approaches can be safely used for placement of the Denali filter. Femoral venous access involved a shorter fluoroscopy time without any differences in filter tilt and filter tip abutment compared to transjugular access.

Purpose To determine the prognostic value of peritumoral edema identified at preoperative breast magnetic resonance (MR) imaging for disease recurrence in patients with invasive breast cancer. Materials and Methods Between January 2011 and December 2012, 353 women (median age, 49 years; range, 27-77 years) with invasive breast cancer who had undergone preoperative MR imaging and mastectomy or breast-conserving surgery were identified. Two radiologists independently reviewed peritumoral edema on the basis of the degree of the signal intensity surrounding the tumor on T2-weighted images. The association of disease recurrence with peritumoral edema and clinical-pathologic features was assessed by using the multivariate Cox proportional hazards model and the integrated discrimination improvement (IDI) and continuous net reclassification improvement (NRI) indexes. Results Twenty-four patients (6.8%) had disease recurrence after 27.2 months of median follow-up. At multivariate analysis, higher N stage (hazard ratio = 4.84, P = .002) and the presence of lymphovascular invasion (hazard ratio = 2.48, P = .044) and peritumoral edema (hazard ratio = 2.77, P = .022) were independent factors associated with disease recurrence. IDI and continuous NRI showed significant improvement in the accuracy of the association with disease recurrence when peritumoral edema was added to established clinical-pathologic features (IDI = 0.061, P < .001; continuous NRI = 0.334, P = .012). Conclusion Peritumoral edema identified at preoperative MR imaging is independently associated with disease recurrence. Peritumoral edema assessment may provide better prognostication in patients with invasive breast cancer. © RSNA, 2018.

Actinomycosis is a slowly progressive, chronic infectious disease. It is caused by the genus Actinomyces, which are gram-positive anaerobic bacteria. It presents as a mass-like lesion, composed of bacterial nidus and characteristic granulomatous inflammatory fibrosis. As such, it has frequently been mistaken for a malignancy. Surgical resection is a common procedure in these patients prior to a definite diagnosis. Although actinomycosis can occur in a variety of regions, including oral-cervicofacial, thoracic, and abdominopelvic cavities, the involvement of the pancreas is very rare. We report a case of a 44-year-old male with a symptomatic actinomycosis caused by a mass in the tail of the pancreas. The diagnosis was made using an endoscopic ultrasound-guided fine needle aspiration biopsy without surgical resection. After the treatment with antibiotics, the pancreatic mass was confirmed to be resolved on the follow-up computed tomography.

To evaluate the prevalence of and factors associated with internal mammary node (IMN) adenopathy on MRI and PET/CT used for initial staging in patients with operable breast cancer. A total of 1320 patients diagnosed with invasive breast carcinoma between January 2011 and December 2015 underwent MRI and PET/CT for initial staging. The patients were considered to have IMN adenopathy when MRI revealed IMNs with the longest diameter of 5 mm or greater and a standardized uptake value greater than that of the mediastinal blood pool/contralateral parasternal area on PET/CT. The prevalence was determined as overall percentage of patients with IMN adenopathy, as well as percentages among patients who received neoadjuvant chemotherapy and those who did not. The association of IMN adenopathy with factors was evaluated using multivariate logistic regression analysis. Of the 1320 patients, 35 patients [2.7 %; 95 % confidence interval (CI) 1.8–3.6 %] had IMN adenopathy, with a total of 49 IMNs. Among patients without and with neoadjuvant chemotherapy (n = 1092 and n = 228, respectively), IMN adenopathy was identified in 13 (1.2 %; 95 % CI 0.6–2.0 %) and 22 patients (9.6 %; 95 % CI 6.0–14.6 %), respectively. Inner tumor location [odds ratio (OR) 5.9; P = .002] and positive axillary lymph node status (OR 4.4; P

To assess the complementary prognostic value of pre-treatment tumor apparent diffusion coefficient (ADC) for the prediction of tumor recurrence in patients with rectal cancer. From March 2012 to March 2013, a total of 128 patients with mid/lower rectal cancer who underwent pre-treatment rectal MRI were enrolled in this retrospective study. Two radiologists in consensus evaluated conventional imaging features (Cimg) in pre-treatment rectal MRI: tumor height from anal verge (≤5 cm vs. >5 cm), T stage (high vs. low), the presence or absence of lymph node metastasis, mesorectal fascia invasion, and extramural venous invasion. The mean tumor ADC values (TumorADC) based on high b-value (0, 1000 × 10−3 mm2/s) diffusion weight images were extracted. A multivariate Cox proportional hazard (CPH) regression was performed to evaluate the association of Cimg and TumorADC with the 3-year local recurrence (LR) rate. Predictive performance of two multivariate CPH models (Cimg only vs. Cimg + TumorADC) was compared using Harrell’s c index (HCI). TumorADC (Adjusted HR, 7.830; 95% CI 3.937–15.571) and high T stage (Adjusted HR, 8.039; 95% CI 2.405–26.874) were independently associated with the 3-year LR rate. The CPH model generated with T stage + TumorADC (HCI, 0.820; 95% CI 0.708–0.932) showed significantly higher HCI than that with T stage only (HCI, 0.742; 95% CI 0.594–0.889) (P = 0.009). In patients with mid/lower rectal cancer, integrating TumorADC to Cimg increases predictive performance of the CPH model than that with Cimg alone for the prediction of LR within 3 years after surgery.

The aim of this study was to determine the diagnostic performance of magnetic resonance imaging (MRI)-categorized T3cd/T4 tumors for identifying high-risk stage II or stage III cancer in patients with curatively resectable colon cancer in comparison to that of multidetector computed tomography (MDCT). Thirty-eight patients with histopathologically indicated adenocarcinomas prospectively underwent MRI of the colon. Two radiologists independently and retrospectively assessed for T-category, including T3 substage (≤ T3ab vs. ≥ T3cd). The diagnostic accuracies and interreader agreements between assessments using each modality were compared using a pairwise comparison of receiver-operating characteristic curves and a weighted κ statistic, respectively. Twenty-nine patients (76.3%) were histopathologically diagnosed with high-risk stage II or stage III colon cancer. The false-positive rate with MRI was lower than that with MDCT (0% vs. 7.9% for reader 1, 2.6% vs. 10.6% for reader 2). The diagnostic performance of MRI was better than that of MDCT across both readers (AUC: 0.707 vs. 0.506 [P = 0.032] for reader 1, 0.651 vs. 0.485 [P = 0.055] for reader 2). Moreover, MRI interreader agreement for the assessment of T3cd/T4 was significantly better than that of MDCT (κ = 0.821 vs. 0.391 [P = 0.017]). The diagnostic performance of MR imaging of the colon may be better than that of MDCT for identifying high-risk stage II or stage III cases. Particularly, colon MRI reduced the false-positive rate and improved the interreader agreement, although further studies with a larger sample size are required.

OBJECTIVES To compare the differences in radiologic and pathologic features of surgically resected chronic obstructive pulmonary disease (COPD)-related adenocarcinomas according to the presence of emphysema. METHODS A total of 216 smokers with surgically resected lung adenocarcinoma were included in this retrospective study, and 102 patients were diagnosed with COPD. We classified COPD patients as emphysematous or non-emphysematous group based on the emphysema severity on computed tomography (CT) and evaluated the differences in the CT and pathologic features between the two groups. The relationship between emphysema and disease-free survival was assessed using a Kaplan-Meier curve. RESULTS Lung adenocarcinomas in emphysema group presented a more aggressive pathologic grade and higher prevalence of solid lesions (vs subsolid lesions) on CT than those in non-emphysematous group (P = 0.006 and

Ultrasonography-guided fine-needle aspiration (US-guided FNA) for axillary lymph nodes (ALNs) is currently used with various techniques for the initial staging of breast cancer and tagging of ALNs. With the implementation of the tattooing of biopsied ALNs, the rate of false-negative results of US-guided FNA for non-palpable and suspicious ALNs and concordance with sentinel lymph nodes were determined by node-to node analyses. A total of 61 patients with breast cancer had negative results for metastasis on US-guided FNA of their non-palpable and suspicious ALNs. The biopsied ALNs were tattooed with an injection of 1–3 mL Charcotrace (Phebra, Lane Cove West, Australia) ink and removed during sentinel lymph node biopsy or axillary dissection. We determined the rate of false-negative results and concordance with the sentinel lymph nodes by a retrospective review of surgical and pathologic findings. The association of false-negative results with clinical and imaging factors was evaluated using logistic regression. Of the 61 ALNs with negative results for US-guided FNA, 13 (21%) had metastases on final pathology. In 56 of 61 ALNs (92%), tattooed ALNs corresponded to the sentinel lymph nodes. Among the 5 patients (8%) without correspondence, 1 patient (2%) had 2 metastatic ALNs of 1 tattooed node and 1 sentinel lymph node. In multivariate analysis, atypical cells on FNA results (odds ratio = 20.7, p = 0.040) was independently associated with false-negative FNA results. False-negative ALNs after US-guided FNA occur at a rate of 21% and most of the tattooed ALNs showed concordance with sentinel lymph nodes.

The prevalence of intraductal papillary mucinous neoplasm (IPMN) has recently increased, and endoscopic retrograde cholangiopancreatography (ERCP) is a major diagnostic modality for IPMN. The aim of our study was to determine the prevalence rate of iatrogenic pancreatitis in the patients with IPMN and the predictive signs on pre-procedural images and endoscopic procedures. At a single center, patients who underwent ERCP between September 2001 and December 2010 were included in this study. The presence of iatrogenic pancreatitis was evaluated and the difference of prevalence in the patients with/without IPMN was determined. Then, a review of cross-sectional images was performed. The prevalence rate of iatrogenic pancreatitis in the patients with IPMN was 20% and that in the patients with other pancreatic cystic lesions was 14%. Mural nodules on images and filling defects on ERCP were more highly detected in the patients without iatrogenic pancreatitis (p = 0.040 and p = 0.027, respectively). In the multivariate analysis, the presence of filling defects correlated with a decreased incidence of iatrogenic pancreatitis (odds ratio = 0.119 and p = 0.047). In this study, the prevalence rate of ERCP-induced pancreatitis in the patients with IPMN was 21%, and the presence of filling defects was associated with a decreased incidence of iatrogenic pancreatitis.

Biliary invasion by hepatocellular carcinoma (HCC) is much less common. Patients manifest obstructive jaundice as the initial complaint, but most of them are inoperable. We report a case of completely improved biliary invasion in HCC after transcatheter arterial chemoembolization (TACE). A 61-year-old woman was referred for evaluation of jaundice. A biliary invasion of huge HCC was confirmed by image of abdominal computerized tomography (CT) and biopsy specimen. After improvement of jaundice by endoscopic retrograde biliary drainage and percutaneous transhepatic biliary drainage, she underwent TACE as a palliative treatment. Follow-up CT showed partial lipiodol uptake in hepatic tumor and its bile duct invasion. In follow-up endoscopic retrograde cholangiopancreatography, occluded cholangiogram showed neither luminal obstruction nor filling defect after removal of biliary stent. Our case suggests that obstructive jaundice, caused by inoperable huge HCC with biliary invasion, may be expected to resolve successfully biliary obstruction by a choice of TACE. Korean J Pancreatobiliary 2014;19(1):31-36

Introduction. Gadoxetate-disodium is a liver-specific MR contrast agent absorbed by hepatocytes via organic anion transporting polypeptide 1B3 and is excreted into the biliary system by multidrug resistance-associated protein 2. It has been suggested that relative parenchymal enhancement on hepatocyte phase image is associated with hepatic function. However, it is not clear whether gadoxetate-disodium-enhanced MRI can be used as a noninvasive fibrosis marker. Thus, the purpose of our study was to evaluate the diagnostic performance of gadoxetate-disodium-enhanced MRI in predicting the hepatic fibrosis stage. Materials and methods. A total of 113 patients who had fibrosis staged according to the Batts and Ludwig score were enrolled: F0 (n = 13), F1 (n = 18), F2 (n = 15), F3 (n = 32), and F4 (n = 35). All patients underwent gadoxetate-disodium-enhanced MRI before confirmation by biopsy (n = 67) or surgery (n = 46). For quantitative analysis, the contrast enhancement index (CEI) was calculated by measuring the signal intensity (SI) in liver and paraspinal muscle using a region of interest, as follows: CEI = (liver SI/paraspinal muscle SI) 20 min hepatocyte phase image /(liver SI/paraspinal muscle SI) pre-contrast T1-weighted image . The diagnostic performance was evaluated by the ROC curve, adjusted for the prevalence of each fibrosis stage. Results. A significant negative correlation was observed between CEI and fibrosis stage (r = -0.545, P < 0.0001). The adjusted AUROC for CEI in the prediction of mild (≥ F1), moderate (≥ F2), or severe fibrosis (≥ F3) and liver cirrhosis (F4) was 0.668, 0.703, 0.73, and 0.84, respectively. In conclusion, our results demonstrate that quantitative analysis of relative hepatic enhancement using gadoxetate-disodium-enhanced MRI can predict the hepatic fibrosis stage.

OBJECTIVE To investigate if there is difference in hepatic segmental volume distribution according to causes of liver cirrhosis (LC) using computed tomography volumetric analysis. METHODS On computed tomographic scans, hepatic segmental volumes were measured in 90 patients with LC of 4 different causes (alcohol, hepatitis B virus (HBV), hepatitis C virus (HCV), and cryptogenic cirrhosis). The volumetric indices were compared. RESULTS The volume proportion of the lateral segment in the liver in patients with HBV was significantly higher than in the patients with HCV (P = 0.038). Hepatic volume distribution in alcoholic LC showed differences: larger caudate lobe volume than HBV- and HCV-induced LC (P = 0.029 and P = 0.031), larger right lobe volume (P = 0.043) and smaller proportion of the lateral segment in the liver (P = 0.003) than in HBV-induced LC. CONCLUSIONS Computed tomography volumetric analysis showed differences in hepatic segmental volume distribution in cirrhotic patients according to causes of LC.

Purpose To describe our experience with transcatheter n-butyl-2-cyanoacrylate (NBCA) embolization of refractory enteric or biliary fistulas. Materials and Methods Between March and December 2009, a retrospective analysis of patients with enteric or biliary fistulas revealed 11 cases unresponsive to drainage and treatment with NBCA (seven men; age range, 36–81 y). Fistula output ranged from 100 to 300 mL per day. Embolization was performed 20–55 days (mean, 32 d) after a fistula was noted on a radiograph of the abscess performed through a previously placed percutaneous drainage catheter. Digital subtraction imaging of the abscess via the percutaneous drainage catheter was used to show enteric or biliary communications and fistula tract. After the fistula tract was identified, it was cannulated under fluoroscopic guidance with a guide wire and a 5-F angiographic catheter. In embolization procedures, NBCA was deployed to fill and seal the entire tract and remnant abscess cavity. Results In all patients, enteric or biliary fistula output ceased after one or two procedures without any complications. No recurrence was noted during follow-up of 9–17 months. Conclusions Persistent enteric or biliary fistulas can be treated successfully by transcatheter image-guided NBCA embolization. This may decrease the morbidity associated with prolonged external drainage and avert the need for surgery.

Background Most ductal carcinoma in situ (DCIS) of the breast is asymptomatic and usually manifests as calcifications in screening mammography. On the other hand, little is known about ultrasonographic (US) features of asymptomatic DCIS, for US is rarely used for the diagnosis and evaluation of DCIS because of low sensitivity in detecting microcalcifications. Purpose To evaluate US detection and characterization of DCIS in asymptomatic women and correlate these imaging findings with the histopathologic features. Material and Methods This retrospective study evaluated mammographic and US images of 60 DCIS cases from 59 asymptomatic women. US was performed in knowledge of mammographic findings. The following histopathologic parameters were analyzed: Van Nuys classification, architectural pattern, and presence of microinvasion. Image detectability and US features were correlated with these histopathologic parameters. Results Of the 54 cases (90.0%) detected on mammography, 48 cases (88.9%) had microcalcifications only, 5 (9.3%) had microcalcifications with associated density, and 1 (1.9%) had soft tissue density alone. Of the 38 cases (63.3%) identified by US, 29 cases (76.3%) had a mass with or without microcalcifications, six (15.8%) had microcalcifications only, and three (7.9%) had other findings. US identified lesions were associated with higher Van Nuys groups, microinvasion and comedocarcinoma ( P = 0.044, P = 0.024, and P = 0.032, respectively). The most common US finding was a not-circumscribed, oval mass with parallel orientation and normal acoustic transmission. Microcalcifications were seen on US in 31 (81.6%) of the 38 US visible cases; this finding showed a trend of association with Van Nuys group 2 and 3 but was not statistically significant ( P = 0.063). Conclusion When DCIS was identified on US, it was associated with more aggressive histopathologic type. However, mammographic correlation is essential to differentiate benign from malignant lesion in cases seen by US; US findings of asymptomatic DCIS had a low suspicion of malignancy.

This study investigated the efficacy of locoregional ultrasonography (LRUS) for the detection of recurrence in asymptomatic patients who underwent mastectomy and the impact of LRUS on prognosis.A total of 1796 LRUSs were performed in 874 asymptomatic patients who showed no clinical evidence of recurrence after mastectomy. Ultrasonography (US) results were considered positive when US detected any masses at the mastectomy bed or suspicious regional lymph nodes. The final diagnosis of each patient was based on cytopathology results or data collected during the follow-up. The median follow-up was 37 months. We evaluated diagnostic performance of LRUS at the detection of locoregional recurrence (LRR) and compared overall survival of asymptomatic patients with recurrences to that of symptomatic patients with recurrences.Of 874 asymptomatic patients, 57 patients (6.5%) had suspicious LRR on LRUS. The positive predictive value (PPV) of LRUS was 26.3% with 15 recurrences diagnosed in 15 patients (cancer detection rate, 1.7% per patient and 0.8% per examination). Asymptomatic patients with recurrences had better survival compared with symptomatic patients with recurrences (P = .034).LRUS during breast US after mastectomy for breast cancer was helpful for the early detection of recurrence and may lead to a better prognosis for patients.

Purpose: To assess the usefulness of an ultrasound (US)-guided peritoneal biopsy for the solitary peritoneal thickening visualized as only infiltrated fat on a computed tomography (CT) scan. Materials and Methods: This retrospective study included 36 patients (16 males, 20 females; mean age, 51.7 years) who underwent a US-guided biopsy for the solitary peritoneal thickening of unknown cause visualized as only infiltrated fat without an apparent mass formation on a CT scan. The rate of the specific histopathological diagnosis and accuracy for the diagnosis of malignant disease was assessed. Results: The procedure was technically successful with the acquisition of an adequate amount of the specimen for microscopic examination from all patients. A specific histopathological diagnosis was made in 31/36 patients (86.1%): peritoneal carcinomatosis in 15/31 (48.4%), tuberculous peritonitis in 15/31 (48.4%) and panniculitis in 1/31 (3.2%). A non-specific histopathological diagnosis was made in 5/36 (13.9%): chronic inflammation in 4/5 (80%) and mesothelial hyperplasia in 1/5 (20%). The procedure showed sensitivity of 83.3%, with a specificity of 100%, a positive predictive value of 100%, a negative predictive value of 85.7%, and an accuracy rate of 86.1% for the diagnosis of malignant diseases. Conclusion: The US-guided peritoneal biopsy is a fairly accurate diagnostic procedure for the peritoneal thickening visualized as only infiltrated fat on a CT scan, and it can be used before performing laparoscopic or an open biopsy.

Duodenal duplication cysts are rare congenital malformations. Most symptomatic cases are diagnosed in children and usually present with obstructive findings or bleeding symptoms. Treatment traditionally involves surgical resection, which can be often difficult because of the close proximity of the cysts to the papilla and bilopancreatic confluence. Endoscopic therapy has been used as an alternative to open surgery in a few selected cases. We report a case with a duodenal duplication cyst containing a brown pigmented stone within the cystic lumen. He was visited because of sudden right upper quadrant abdominal pain. An abdominal computed tomography revealed the presence of a cyst with a stone, which was finally removed by endoscopic resection.

The placement of self-expanding metal stents (SEMS) is a safe and effective definitive procedure for the palliation of malignant colorectal obstruction. In this study, the clinical outcomes, including the technical and clinical success rates, and the risk factors associated with the long-term outcomes of palliative SEMS were evaluated.From February 2002 to April 2008, 39 patients (18 men and 21 women) with malignant colorectal obstruction underwent placement of uncovered or covered stents under fluoroscopic or endoscopic guidance. The mean age of the patients was 64.5 +/- 14.6 years (range, 37-96 years).The technical success rate was 100% (39/39), and the clinical success rate was 87.2% (34/39). Five cases had failed relief of the obstruction due to the development of migration in two patients, two malfunctions, and one perforation. Four patients experienced late complications: migration managed with a palliative colostomy in two patients, tumor ingrowth managed successfully with a second stent in one patient, perforation with an intraabdominal abscess at the upper margin of the stent 4 months after stenting in one patient. The location of the obstruction and the length of the stent were significant factors associated with a good outcome. Shorter stents (10 cm) had better outcomes than longer stents (or=10 cm; p = 0.008), and patients with a distal colorectal obstruction had better outcomes than those with a proximal colorectal obstruction (p = 0.015).Patients with bowel obstruction involving a short segment and those with a distal obstruction had better stent outcomes.

The purpose of this study is to demonstrate the feasibility, safety, and success of percutaneous paracoccygeal catheter drainage of deep pelvic abscesses using a combination of sonography and fluoroscopic guidance.From April 2005 to December 2006, under sonography and fluoroscopic guidance, sixteen patients with deep pelvic abscess underwent percutaneous paracoccygeal drainage. The causes of pelvic abscesses were post-operative complications. The patient was in prone position; the puncture site was first evaluated with sonography. After local anesthesia, a thin needle (22 G) was positioned along the lateral margin of the coccyx to avoid an eventual injury of sciatic nerve or vessels into the deep pelvic abscess under sonography guidance. Small dose of contrast was injected under fluoroscopy to verify the needle. With Seldinger technique catheters were placed for drainage. Catheter drainage was maintained for 9-40 days. Patients underwent clinical follow-up and subsequent imaging as necessary.Neither significant complications nor technical failures were observed. A complete resolution of the abscess was achieved in 14 patients, and significant resolution of abscess was also observed in the other 2 patients.Sonography and fluoroscopic guided percutaneous paracoccygeal drainage is safe, feasible and efficient approach in the treatment of deep pelvic abscess.

The purpose of this study is to demonstrate the feasibility, safety, and success of percutaneous transhepatic biliary drainage (PTBD) using a combination of ultrasound and fluoroscopy guidance in patients with nondilated bile ducts.Between January 2005 and July 2007, 50 patients with nondilated bile ducts underwent ultrasound-and-fluoroscopy guided PTBD. The underlying disease processes were divided into biliary obstruction (n = 38) and bile leakage (n = 12). We used ultrasound guidance when puncturing a bile duct and during cholangiography. We punctured along the course of the targeted bile duct or portal vein when the bile duct was not visualized, which we termed the "parallel technique." This method made it possible for us to cannulate the peripheral bile duct successfully, even when its course was not visualized well by sonography. We then installed a drainage catheter under fluoroscopy guidance. The technical success and complications of the procedure were evaluated.Neither significant complications nor technical failures were observed. There were only four minor complications: transient hemobilia (n = 3) and fever (n = 1).Ultrasound-and-fluoroscopy guided PTBD in patients with nondilated bile ducts is a safe, feasible, and efficient procedure for the palliation of biliary obstruction and leakage.

Recently, a few studies have raised the question of whether preoperative chemoradiotherapy (PCRT) is essential for all T3 rectal cancers. This case-matched study aimed to compare the long-term outcomes of surgery alone with those of PCRT + surgery for magnetic resonance imaging (MRI)-assessed T3ab (extramural depth of invasion ≤5 mm) and absent mesorectal fascia invasion (clear MRF) in mid/lower rectal cancer patients.From January 2006 to November 2012, 203 patients who underwent curative surgery alone (n = 118) or PCRT + surgery (n = 85) were enrolled in this retrospective study. A 1:1 propensity score-matched analysis was performed to eliminate the inherent bias. Case-matching covariates included age, sex, body mass index, histologic grade, carcinoembryonic antigen, operation method, follow-up period, tumor height, and status of lymph node metastasis. The end-points were the 5-year local recurrence (LR) rate and disease-free-survival (DFS).After propensity score matching, 140 patients in 70 pairs were included. Neither the 5-year LR rate nor the DFS was significantly different between the 2 groups (the 5-year LR rate, P = 0.93; the 5-year DFS, P = 0.94). The 5-year LR rate of the surgery alone was 2% (95% confidence interval [CI] 0.2%-10.9%) versus 2% (95% CI 0.2%-10.1%) in the PCRT + surgery group. The 5-year DFS of the surgery alone was 87% (95% CI 74.6%-93.7%) versus 88% (95% CI 77.8%-93.9%) in the PCRT + surgery group.In patients with MRI-assessed T3ab and clear MRF mid/lower rectal cancer, the long-term outcomes of surgery alone were comparable with those of the PCRT + surgery. The suggested MRI-assessed T3ab and clear MRF can be used as a highly selective indication of surgery alone in mid/lower T3 rectal cancer. Additionally, in those patients, surgery alone can be tailored to the clinical situation.

Background The value of diffusion-weighted imaging (DWI) for reliable differentiation between pathologic complete response (pCR) and residual tumor is still unclear. Recently, a few studies reported that histogram analysis can be helpful to monitor the therapeutic response in various cancer research. Purpose To investigate whether post-chemoradiotherapy (CRT) apparent diffusion coefficient (ADC) histogram analysis can be helpful to predict a pCR in locally advanced rectal cancer (LARC). Material and Methods Fifty patients who underwent preoperative CRT followed by surgery were enrolled in this retrospective study, non-pCR ( n = 41) and pCR ( n = 9), respectively. ADC histogram analysis encompassing the whole tumor was performed on two post-CRT ADC600 and ADC1000 (b factors 0, 600 vs. 0, 1000 s/mm2) maps. Mean, minimum, maximum, SD, mode, 10th, 25th, 50th, 75th, 90th percentile ADCs, skewness, and kurtosis were derived. Diagnostic performance for predicting pCR was evaluated and compared. Results On both maps, 10th and 25th ADCs showed better diagnostic performance than that using mean ADC. Tenth percentile ADCs revealed the best diagnostic performance on both ADC600 (AZ 0.841, sensitivity 100%, specificity 70.7%) and ADC1000 (AZ 0.821, sensitivity 77.8%, specificity 87.8%) maps. In comparison between 10th percentile and mean ADC, the specificity was significantly improved on both ADC600 (70.7% vs. 53.7%; P = 0.031) and ADC1000 (87.8% vs. 73.2%; P = 0.039) maps. Conclusion Post-CRT ADC histogram analysis is helpful for predicting pCR in LARC, especially, in improving the specificity, compared with mean ADC.

Collateralization of a hemodynamically compromised internal carotid artery (ICA) by the vasa vasorum is rare. We report the serial radiologic findings of an apparent hypertrophied vasa vasorum of the cervical ICA, which was secondary to arterial dissection.

경피적 미세흡인생검술(fine needle aspiration biopsy; 이하 Purpose: To evaluate the feasibility and diagnostic accuracy of the balloon dilatation biopsy for the biliary stricture through the percutaneous transhepatic biliary drainage (PTBD) tract. Materials and Methods: The study included 35 patients who underwent balloon dilatation biopsy for the biliary stricture through the PTBD tract. Balloon dilatation was done with a balloon catheter of 10-mm or 12-mm diameter. Soft tissue adherent to the retrieved balloon catheter and soft tissue components separated by gauze filtration of evacuated bile were sampled for histopathologic examination. The results were compared with the final diagnosis which was made by clinical and imaging follow-up for mean 989 days (n = 34) and surgery with histopathologic examination (n = 1). Procedure-related complications and diagnostic accuracy were assessed. Results: Tissues suitable for histopathologic examination were obtained in 31 out of 35 patients (88.6%). In 3 patients, self-limiting hemobilia was noted. No major complication was noted. The sensitivity, specificity, diagnostic accuracy, positive and negative predictive values for diagnosis of malignant stricture were 70.0%, 100%, 90.3%, 100%, and 87.5%, respectively. Conclusion: Balloon dilatation biopsy of the biliary stricture through the PTBD tract is a feasible and accurate diagnostic method. It can be a safe alternative to the endoscopic retrograde cholangiography biopsy or forceps biopsy through the PTBD tract. Index terms Radiology, Interventional Biopsy Bile Ducts Cholangiocarcinoma

In ultra-early aneurysm surgery, the few hours from admission to aneurysm clipping present the greatest risk for an in-hospital recurrent hemorrhage, the development of acute hydrocephalus, and severe brain edema. Thus, severe brain swelling encountered after dural opening in a craniotomy can sometimes not be explained by a preoperative computed tomography (CT) scan. Therefore, neurosurgeons need a diagnostic tool to determine the exact cause of the brain swelling to apply appropriate intraoperative management. Accordingly, the authors propose a designated optimal ultrasound window for evaluating brain swelling during a pterional craniotomy, and assess its diagnostic usefulness and clinical impact. Intraoperative ultrasonography was performed during pterional craniotomies to identify the causes of severe brain swelling in 23 out of 185 patients treated using a policy of ultra-early treatment after a subarachnoid hemorrhage. Paine’s point was used as the sonographic window to provide axial images showing the anterior interhemispheric fissure, lentiform nucleus, insular cortex, sylvian fissure, and ventricular system. The intraoperative ultrasonography revealed significant changes from the preoperative CT findings in 9 (39.1 %) of the 23 patients. These changes included the occurrence of an intracerebral hemorrhage (ICH, n = 2) related to aneurysm rebleeding with aggravated hydrocephalus and the development (n = 5) or aggravation (n = 2) of acute hydrocephalus without rebleeding. Meanwhile, for 14 (60.9 %) of the 23 patients, the ultrasonography showed no intracranial changes. For the total 23 patients with severe brain swelling, the intraoperative management included aspiration of an ICH (n = 3), a ventriculostomy (n = 16), and medical management (n = 8) with additional mannitol and/or mild hyperventilation. When severe brain swelling is encountered during a pterional craniotomy for clipping a ruptured aneurysm, an intraoperative ultrasonography technique using Paine’s point as a sonographic window provides useful and reliable diagnostic information on the causes of the brain swelling, enabling the neurosurgeon to select appropriate intraoperative management.

To evaluate the efficacy of ultrasonographically (US)-guided percutaneous cholecystocholangiography (PCC) for early diagnosis and characterization of biliary atresia in infants with cholestatic liver disease.Institutional review board approval was obtained for this study. Parental informed written consent was obtained. From October 2003 to August 2010, 22 infants (12 male, 10 female; age range, 1-138 days) were referred to the radiology department for PCC. Indications for PCC were suspected biliary atresia at 24-hour delayed technetium 99m-diisopropyl-phenylcarbamoylmethyl-iminodiacetic acid (DISIDA) scintigraphy because no excretion was observed in the small bowel (n = 17) or when the results of the scan or liver biopsy could not be obtained within 3 days because of a delay in schedule (n = 5). A diagnosis of biliary atresia was excluded when there was contrast material visualized in the gallbladder, biliary system, and passage to the duodenum. Patients with biliary atresia underwent surgery as the reference standard.Among the 18 patients who underwent successful PCC, biliary atresia was excluded in 13, with diagnoses as follows: total parenteral nutrition-associated cholestasis (TPNAC) (n = 6), neonatal hepatitis (n = 4), congenital syphilis (n = 1), neonatal lupus (n = 1), and congenital cytomegalovirus hepatitis (n = 1). Biliary atresia was diagnosed in five patients (four with type IIIb and one with type IIIa) and was confirmed at surgery. In four infants in whom US-guided gallbladder puncture had failed, biliary atresia (n = 2) and TPNAC (n = 2) were diagnosed.PCC is a safe and useful technique for early exclusion when biliary atresia cannot be ruled out after traditional screening tests; in addition, it may be useful for preoperative type determination of biliary atresia. © RSNA, 2011.

Pancreatic pseudocysts are focal fluid collections that develop as a result of inflammatory diseases of the pancreas. They are managed conservatively or with a drainage procedure. Their radiological appearance can mimic cystic neoplasms of the pancreas. Pancreatic cystic neoplasms include various neoplasms with a wide range of malignant potential. Here, we report a patient with a pancreatic pseudocyst that presented with macrocystic attributes on endoscopic ultrasound.

Background: Inadequate remnant liver volume is a major cause of postoperative liver failure. Preoperative portal vein embolization (PVE) is used clinically to prevent postoperative liver insufficiency. Purpose: To evaluate the efficacy and safety of preoperative portal vein embolization, by using a combination of gelatin sponge and histoacryl to induce hypertrophy of future liver remnant (FLR) in patients with a hepatobiliary malignancy. Material and Methods: PVE using a combination of gelatin sponge and histoacryl glue was performed in 11 patients (nine men, two women; mean age 60 years, range 46–70 years). These patients were diagnosed with a hepatobiliary malignancy before surgery and their FLR volumes were judged as insufficient to allow for safe resection (FLR Results: PVE was successful in all patients, and there were no procedural complications. The enlargement of nonembolized liver lobe was 30% (mean 118 cm3). A planned hepatectomy was cancelled in four patients due to the presence of a late-detected extrahepatic metastasis. Seven of the 11 patients underwent hepatectomy without complications. Conclusion: Preoperative PVE with a combination of gelatin sponge and histoacryl glue is a safe and effective procedure to induce hypertrophy of nonembolized parts of the liver.

Objective: The present study analyzed the functional insertion/deletion polymorphism in the promoter region of NFKB1 gene and their impact on the prognosis for patients with gastric adenocarcinoma. Methods: Four hundred and seventy two consecutive patients with curatively resected gastric adenocarcinoma were enrolled in the present study. The genomic DNA was extracted from paraffin-embedded tissue and the 294 insertion/deletion ATTG polymorphism of NFKB1 determined using a polymerase chain reaction‐restriction fragment length polymorphism assay. Results: The NFKB1 promoter gene polymorphism was successfully amplified in 97.8% of the cases. There were no sexual differences in relation to the genotype and allele. No correlation was observed between the frequency of the genotype or allele and the T, N or M stage. The multivariate survival analysis showed no association between the NFKB1 294 insertion/ deletion promoter polymorphism and the disease-free survival or overall survival of the patients with gastric cancer. Conclusions: The functional NFKB1 promoter polymorphism was not found to be a prognostic marker for Korean patients with surgically resected gastric adenocarcinoma.

Although endovascular techniques are widely used for the treatment of cerebral aneurysms, the immediate postprocedural brain CT findings have not been reported. Therefore, in the present study we assessed the immediate postprocedural brain CT findings following the uneventful coil embolization of cerebral aneurysms.Included in the study were 59 patients with 61 cerebral aneurysms after uncomplicated coil embolization. Acute subarachnoid hemorrhage was present with 32 of the 61 aneurysms. All patients underwent a brain CT scan just before and within 2 h after the endovascular treatment. If the postprocedural CT scan revealed any new findings, a follow-up CT scan and/or MRI were performed within 24 h. The variables related to the abnormal CT findings were also evaluated.Among the 61 immediate brain CT scans, 26 (43%) showed abnormal findings, including cortical contrast enhancement (n=21, 34%), subarachnoid contrast enhancement (n=8, 13%), intraventricular contrast enhancement (n=5, 8%), and striatal contrast enhancement (n=2, 3%). Single or mixed CT findings were also seen. None of the 61 aneurysms was associated with new neurological symptoms after endovascular treatment, and all patients made an uneventful recovery. Abnormal findings were more likely to be found with lower body weight and with increased corrected amounts of contrast material and heparin (P0.05).After uneventful endovascular treatment of cerebral aneurysms, the immediate brain CT findings can reveal various patterns of abnormal contrast enhancement. Recognizing the immediate brain CT findings is important, as they can mimic various diseases.

Purpose: The aim of our study was to evaluate the risk of malignancy and to determine which clinical variables differentiate between benign and malignant focal breast lesions found incidentally on 18 F-flourodeoxyglucose positron emission tomography and computed tomography (FDG PET/CT). Methods: From March 2005 to October 2011, 21,224 women with no history of breast cancer underwent FDG PET/CT at three university-affiliat ed hospitals. We retrospectively identified 214 patients with inci dental focal hypermetabolic breast lesions and grouped them into benign and malignant lesion groups. Of the 214 patients, 82 patients with 91 lesions were included in this study. All lesions were confirmed histologically or were assessed by follow-up im aging for greater than 2 years. The patient age, maximum standardized uptake value (SUVmax), lesion size on ultrasonography (US), and Breast Imaging-Reporting and Data System (BI-RADS) category on US in conjunction with mammography were compared between the groups. Multivariate logistic regression analysis was used to identify independent factors associated with malignancy. Results: The risk of malignancy was 29.7% (27/91) in breast incidentalomas detected by FDG PET/CT. The univariate analysis showed that the patient age, SUVmax, tumor size, and BI-RADS category differed significantly between the malig nant and benign groups. The multivariate analysis showed that the BI-RADS category was the only significant factor differentiat ing benign from malignant lesions (p= 0.002). Conclusion: BIRADS category based on US in conjunction with mammography was the only useful tool to differentiate between malignant and benign lesions in breast incidentalomas on FDG PET/CT.

Purpose: The aim of this study was to investigate the causes of under-staging in patients with advanced gastric cancer that was proven to be unresectable after a laparotomy. Materials and Methods: We retrospectively analyzed 25 gastric cancer patients who had undergone a diagnostic laparotomy between 2001 and 2005. For the preoperative evaluation, spiral CT and multidetector-row CT were performed. We analyzed the clinicopathologic features of patients and compared the image findings and the results of surgery. The causes of under-staging were divided into 3 groups; patient factor, CT factor, and interpretation factor. Results: Grossly, there were 12 cases of Borrmann type-III tumors and 13 cases of Borrmann type-IV tumors. The most frequent histologic type was poorly differentiated adenocarcinomas (8 cases) and signet ring cell carcinomas (7 cases). There were 13 cases of adjacent organ invasion, and the pancreas was the most frequently invaded organ (9 cases). There were 17 cases of peritoneal metastasis, and 3 cases of distant lymph node metastasis. For the cause of under-staging, there were four cases of patient factor, 19 cases of interpretation factor, and 9 cases of CT factor. In three cases, the cause of under-staging could not be identified. Conclusion: CT interpretation factor was the most frequent cause of under-staging in the preoperative diagnosis with gastric cancer patients. Therefore, more cautious CT interpretation is necessary to avoid unnecessary laparotomies in gastric cancer patients.