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With recent advances in imaging technology, the frequency of detecting musculoskeletal lesions has also increased. Percutaneous image-guided needle biopsy is occasionally required for the diagnosis of such lesions. Moreover, in the era of personalized cancer care, chances in histopathological diagnosis and the importance of histopathological diagnosis by percutaneous needle biopsy are increasing. However, as percutaneous needle biopsy is not a common procedure for musculoskeletal lesions, careful planning and the application of adequate techniques such as hydrodissection and the trans-osseous approach are occasionally required. In this review, we have summarized the indications and techniques for percutaneous image-guided needle biopsy for musculoskeletal lesions, including lymphatic lesions.

Introduction Preoperative embolization for metastatic spinal cord compression (MSCC) has a risk of spinal ischemia. This study aimed to assess the efficacy and safety of preoperative embolization in patients with MSCC and evaluate the use of computed tomography (CT) angiography for the detection of the radiculomedullary arteries (RMA). Methods This retrospective study included 20 patients (12 men and 8 women; median age, 66 years), who underwent preoperative embolization before a decompression surgery, which corresponded to 22 embolization procedures. The detection ability of RMA was evaluated using angiography and selective CT angiography. Surgical data including intraoperative blood loss and transfusion were also evaluated. Results Six RMAs were identified at the levels of affected vertebrae and one level above and below in the diagnostic spinal angiography. In addition to spinal angiography, adjunctive selective CT angiography allowed visualization of another five RMAs. Overall, 11 RMAs were identified in 9 patients. Preoperative embolization was successfully achieved in all patients. As regards complications related to embolization procedure, palsy exacerbated in one patient (4.5%), which improved postoperatively. During the surgical procedure, the mean intraoperative blood loss was 353.4±254.2 mL without intraoperative transfusion in all patients. Conclusions The present study showed small amounts of intraoperative blood loss without any severe complications related to preoperative embolization. Selective CT angiography was a useful technique to detect RMAs and contributed to the safety of preoperative embolization.

Background This study was performed to evaluate the clinical outcomes of hybrid treatment involving surgical resection and percutaneous radiofrequency ablation for patients with multiple lung metastases. Methods Seventeen patients (6 men, 11 women; median age, 52 years; range, 16–78 years) underwent hybrid treatment involving surgery and radiofrequency ablation to treat multiple lung metastases (median number, 4; range, 2–26) between May 2014 and February 2020. The primary lesions were colorectal carcinoma (n = 9), uterine endometrial carcinoma (n = 3), osteosarcoma (n = 2), renal cell carcinoma (n = 1), glottic carcinoma (n = 1), and fibrolamellar hepatocellular carcinoma (n = 1). Twenty‐four sessions each of surgery and radiofrequency ablation were performed. Safety, disease‐free survival, and overall survival were evaluated. Safety was assessed according to the Clavien‐Dindo Classification. Results A grade IVa adverse event of empyema developed in one patient (4%, 1/24) after surgery. A grade IIIa adverse event of pneumothorax and a grade II adverse event of lung abscess occurred in four (17%, 4/24) and one session (4%, 1/24) after radiofrequency ablation, respectively. During the median follow up of 34 months (range, 8–67 months), 10 patients (59%, 10/17) developed new metastases. The 5‐year disease‐free survival rate was 32%. Four or fewer lung metastases (p = 0.008) and metastases from colorectal carcinoma (p = 0.02) were factors significantly associated with longer disease‐free survival. One patient (6%, 1/17) died of tumor progression 29 months after initial treatment. The 5‐year overall survival rate was 88%. Conclusions The strategy of hybrid treatment involving surgery and radiofrequency ablation may offer good outcomes for patients with multiple lung metastases., Hybrid therapy involving surgical resection and percutaneous radiofrequency ablation for multiple lung metastases was effective, with 5‐year disease‐free and overall survival rates of 32% and 88%, respectively. Patients with four or fewer lung metastases and metastases from colorectal carcinoma appear to be good candidates for hybrid therapy.

Walled-off pancreatic necrosis (WOPN) is defined as encapsulated necrotic tissue after severe acute pancreatitis. Treatment strategies for WOPN can be challenging. Although open surgical necrosectomy is the standard treatment for WOPN, it is associated with high rates of morbidity and mortality. Endoscopic necrosectomy, introduced recently, is a treatment option that produces lower rates of morbidity than does open surgery. We report a case of severe WOPN that could not be treated with the usual procedures. Although endoscopic necrosectomy of the left subphrenic and prepancreatic spaces was technically impossible, these spaces could be percutaneously drained. Finally, sufficient drainage of these spaces was achieved with endoscopic necrosectomy through the internal lumen of the self-expandable metallic stent placed percutaneously. This procedure was performed by an endoscopist and an interventional radiologist, and the multidisciplinary approach was useful.

This study aimed to retrospectively evaluate the safety and efficacy of ureteral stent placement using the rendezvous technique for the treatment of postoperative ureteral complications in cancer patients. From January 2005 to April 2015, 19 patients (2 men and 17 women; median age, 59; range, 42–79 years old) with unilateral ureteral lesions (ureteral leakages in 6, strictures in 4, and both in 9) underwent ureteral stent placement using the rendezvous technique. Percutaneous nephrostomy was performed, and stent placement was attempted via antegrade and retrograde approaches. The technical success, procedure-related complications, and clinical success were retrospectively analyzed. The median follow-up period was 29.8 months (range, 0.3–116.5 months). The ureteral stent placement was successful in 17 out of 19 patients (89.5%). Double J ureteral stent was used in 6 patients, and straight catheter as an internal–external nephro-ureteral stent was used in 11 patients. The rendezvous technique was used in the retroperitoneal space and urinary tract in 6 and 11 patients, respectively. No major complications related to the rendezvous technique occurred. Finally, 4 patients achieved stent-free condition (21.1%), and periodic stent exchange was continued in 9 (47.4%). However, permanent external drainage and surgical reconstruction were needed in 4 (21.1%) and 2 (10.5%) patients, respectively. The final clinical success rate was 68.4% (13 out of 19 patients). Ureteral stent placement using the rendezvous technique for the treatment of postoperative ureteral complications in cancer patients is safe and may be alternative to permanent external drainage and invasive surgical reconstruction. Level 4, Case series.

To evaluate the outcomes of radiofrequency ablation (RFA) on lung tumors1 cm in maximum diameter.Twenty-eight patients (12 male, 16 female; median age, 59 years; mean age, 58 ± 16 years; range, 16-78 years) who underwent RFA for lung tumors1 cm in diameter between November 2009 and September 2018 were included in this study. Thirty-five tumors (median size, 8.4 mm; mean size, 7.7 ± 1.9 mm; range, 3.6-9.9 mm) were treated with 33 sessions of RFA. Technique efficacy and safety were subsequently evaluated. Initial and secondary technique efficacy were defined as complete ablation without residual tumor or local tumor progression after initial and repeat RFA, respectively. Safety was evaluated according to the Common Terminology Criteria for Adverse Events, version 5.0.Residual tumor remained for 1 tumor (3%, 1/35) and local tumor progression was found in 2 tumors (6%, 2/35). Initial technique efficacy rate was therefore 91% (32/35). The remaining 3 tumors were treated by repeat RFA (secondary technique efficacy rate: 100%, 35/35). Initial technique efficacy rate was significantly lower for tumors treated with starting energy ≥ 20 W (P = 0.02) and showing a quick increase in tissue impedance (P = 0.01). There were 4 grade 2 adverse events (12%, 4/33) comprising pneumothorax requiring chest tube placement, and 14 grade 1 adverse events comprising self-limiting pneumothorax (36%, 12/33) and pulmonary parenchymal hemorrhage (6%, 2/33).To achieve good outcomes for lung tumors1 cm, radiofrequency energy should be started at20 W. Application of manual mode ablation might be considered when delivery of power cannot be continued due to a quick increase in tissue impedance.

Background:Totally implantable venous access devices (TIVADs) have played an important role of medical oncology practice. However, operators sometimes encounter considerable difficulty when removing TIVADs. This study aimed to investigate the incidence of difficult TIVAD removal, determine associated risk factors, and investigate interventional radiology (IR) approaches to difficult removal., Methods:A total of 514 TIVAD removal procedures performed in a single-center between January 2014 and May 2021 were retrospectively analyzed to determine incidence of difficult removal and associated risk factors. IR approaches applied in difficult removal cases were also reviewed., Results:The incidence of difficult removal was 7.4% (38/514). In univariable analysis, indwelling duration, silicone catheter, and subcutaneous leakage of fluid were identified as significant risk factors for difficult removal. Multivariable analysis showed that indwelling duration per year (odds ratio (OR), 1.46; 95% confidence interval (CI), 1.28-1.67; p < 0.01) and subcutaneous leakage of fluid (OR, 6.04; 95% CI, 2.45-14.91; p < 0.01) were significantly associated with difficult removal. In the 38 difficult removal cases, 32 TIVADs could be removed using more dissection and traction than the standard removal method. In the other 6, TIVADs were successfully removed by using several IR techniques, including insertion of a guide wire (n = 1), dissection using an introducer sheath (n = 2), pushing with a dilator (n = 1), and pulling with a snare (n = 2)., Conclusion:Difficult TIVAD removal is uncommon. However, operators should expect it when removing long indwelling TIVADs and those with subcutaneous leakage. IR approaches to difficult removal are minimally invasive and can be useful.

To evaluate and compare the clinical outcomes between percutaneous gallbladder drainage (PGBD) and percutaneous gallbladder aspiration (PGBA) for acute cholecystitis after biliary stenting for malignant biliary obstruction. Twenty-six and 14 patients underwent PGBD and PGBA, respectively, for acute cholecystitis after biliary stenting for malignant obstruction. The technical success rate, clinical effectiveness, and safety were compared between the 2 groups. Technical success was achieved in all patients. Clinical effectiveness rate was significantly higher in the PGBD group than in the PGBA group [100% (26/26) vs. 57% (8/14), p

Objectives/hypothesis The present study aimed to investigate the efficacy of transarterial embolization (TAE) for bleeding in patients with head and neck cancer (HNC) and to evaluate the prognostic factors after TAE. Study design Outcome study. Methods This retrospective study included 31 consecutive patients (27 men and 4 women; median age, 61 years) who presented uncontrollable hemorrhage associated with HNC and underwent emergency TAE at our institution during a 10-year period (January 2011-December 2020). This corresponded to 40 TAE procedures, including 27 cases with an unstable status (circulatory and/or respiratory insufficiency) and 10 cases with carotid blowout syndrome. The technical success rate and adverse events were analyzed on a per-procedure basis. The rebleeding and overall survival (OS) rates were analyzed on a per-patient basis, and the factors related to OS were evaluated. Results The technical success rate was 100%. As an adverse event, cerebral infarction was found in three cases with carotid blowout syndrome. The rebleeding rate at 30 days after TAE and in the follow-up period (range, 9-3,004 days) was 17.2% and 35.5%, respectively. The median survival time was 263 days (95% confidence interval: 124.0-402.0 days). In the log-rank test, complete remission (CR) of the primary cancer at the time of the first TAE was identified as a significant influencing factor of survival. Conclusion TAE is effective for the treatment of hemorrhage associated with HNC even in patients with an unstable status. Patients with CR can gain a long life span. Level of evidence Level 4 Laryngoscope, 2021.

This study aimed to compare the efficacy and safety of image-guided core needle biopsy (CNB) with those of surgical excision biopsy (SEB) for the diagnosis of lymphoma, and to clarify the indication of CNB in clinical practice.This retrospective study included 263 image-guided CNB cases and 108 SEB cases that were performed at our institution between January 2014 and December 2018. The rate of patients with performance status of grade 1-4 was higher in the CNB group than in the SEB group (43.7% vs. 24.1%, P 0.01). Waiting time to biopsy and diagnosis was shorter for CNB group than for SEB group (4 days vs. 7 days, 13 days vs. 15 days, P 0.01). The rate of biopsy at the deep sites was higher in the CNB group than in the SEB group (53.2% vs. 8.3%, P 0.01). Successful biopsy and complication rates were compared between the 2 groups.There were no significant differences between the CNB and SEB groups in successful biopsy rates (89.0% vs. 93.5%, P = 0.25). The grade 3 complication rate was significantly lower for CNB group than for SEB group (0% vs. 4.6%, P 0.01), although there was no significant difference in overall complication rates (4.9% vs. 6.5%, respectively, P = 0.61).CNB showed high diagnostic yield comparable to SEB for suspected lymphoma. CNB was especially recommended to the cases with low-PS, lesions in the deep sites, and requiring early pathological diagnosis.

This study aimed to predict the treatment response for colorectal liver metastases (CLM) using relative tumor enhancement (RTE) of the hepatobiliary phase (HBP) for patients with no history of chemotherapy. In this retrospective study, we enrolled 26 patients [14 males, 12 females; median age: 58 years (range 37–82 years)] with CLM and no history of chemotherapy between December 2011 and May 2017. Gadoxetic acid-enhanced magnetic resonance imaging was performed before starting chemotherapy and RTE of HBP. The response was evaluated using RECIST ver.1.1, and progression-free survival (PFS) was estimated. Based on the RECIST ver.1.1, there were 15 responders and 11 non-responders. In the tumor, the mean pretreatment RTE values were significantly higher in the responders group than in the non-responders group (37.2% ± 10.9% vs. 17.9% ± 10.5%, respectively; P = 0.0006). When the threshold values of parameters for detecting responders comprised the RTE value of 24.2% (area under the curve value, 0.90), the sensitivity and specificity were 93.3% and 72.7%, respectively. The median follow-up period for 26 patients was 602 days (range 160–1971 days). Although no significant differences were observed in PFS between the groups, the high RTE group tended to take longer to progress than the low RTE group (PFS of the high RTE group did not reach the median). This study suggests that the RTE value of CLM could be a potential biomarker to predict early treatment response.

To evaluate the possibility of pathologic diagnosis and genetic analysis of percutaneous core-needle biopsy (CNB) lung tumor specimens obtained immediately after radiofrequency ablation (RFA). Patients who underwent CNB of lung tumors immediately after RFA from May 2013 to May 2016 were analyzed. There were 19 patients (8 men and 11 women; median age, 69 years; range, 52–88 years) and 19 lung tumors measuring 0.5–2.6 cm (median, 1.6 cm). Thirteen tumors were solid, and 6 were predominantly ground-glass opacity (GGO) on computed tomography. All specimens were pathologically examined using hematoxylin and eosin (H&E) staining and additional immunostaining, as necessary. The specimens were analyzed for EGFR and KRAS genetic mutations. The safety and technical success rate of the procedure and the possibility of pathologic diagnosis and genetic mutation analysis were evaluated. Major and minor complication rates were 11% (2/19) and 53% (10/19), respectively. Tumor cells were successfully obtained in 16 cases (84%, 16/19), and technical success rate was significantly lower for GGO-dominant tumors (50%, 3/6) compared with solid lesions (100%, 13/13, p = 0.02). Pathologic diagnosis was possible in 79% (15/19) of cases based on H&E staining alone (n = 12) and with additional immunostaining (n = 3). Although atypical cells were obtained, pathologic diagnosis could not be achieved in 1 case (5%, 1/19). Both EGFR and KRAS mutations could be analyzed in 74% (14/19) of the specimens. Pathologic diagnosis and genetic analysis could be performed even for lung tumor specimens obtained immediately after RFA.

The purpose of this study was to assess hepatic arterial infusion (HAI) of oxaliplatin combined with intravenous 5-fluorouracil (5-FU) and l-leucovorin (l-LV) in colorectal cancer (CRC) patients with systemic chemotherapy failure in a phase I/II trial. CRC patients with unresectable liver metastases following standard systemic chemotherapy failure were eligible. A catheter-port system for HAI was placed using interventional radiology. In phase I, escalating doses of oxaliplatin for levels 1 and 2 were set at 50 and 100 mg/m2, respectively, and were combined with fixed doses of intravenous 5-FU (200 mg/m2 bolus and 2400 mg/m2/46-h continuous infusion) and l-LV (200 mg/m2). The dose-limiting toxicity (DLT) was assessed, and the recommended dose (RD) was estimated. In phase II, patients receiving RD were included to assess the 6-month survival rate (the expected rate 80%), overall survival time, tumor response, and toxicity. In phase I, none of the six enrolled patients exhibited DLT. RD for oxaliplatin by HAI was estimated as 100 mg/m2. In phase II, seven additional patients were enrolled. In patients receiving RD (n = 10), the disease control rates for total lesions and liver lesions were 30 and 70%, respectively. The 6-month survival rate and the overall survival time were 53.3% and 6.9 months, respectively. There were no adverse reactions equivalent to DLT in any of the patients. The estimated RD for oxaliplatin by HAI in combination with intravenous 5-FU and l-LV was 100 mg/m2. This combination therapy was feasible and safe, but the expected efficacy was not achieved.

A 65-year-old man with hepatocellular carcinoma (HCC) due to alcohol-related liver cirrhosis had undergone transarterial chemoembolization 11 times. However, treatment for HCC was difficult to continue, due to episodic hepatic encephalopathy. He was referred to our hospital for treatment of hepatic encephalopathy, showing a Child-Pugh score of 8 despite medical therapy. Abdominal computed tomography revealed intrahepatic portosystemic venous shunt comprising two shunt tracts from the right posterior portal vein to the inferior vena cava via the right adrenal vein. The larger tract was occluded using an Amplatzer Vascular Plug (AVP) II, and the smaller tract was occluded using an original AVP. The postembolization course was uneventful. Hepatic encephalopathy improved after shunt occlusion and no recurrence had occurred as of one year after the procedure.

In the palliative setting, the necessity of biliary drainage of both liver lobes for malignant hilar biliary obstruction remains controversial. However, bilateral biliary drainage is a reasonable option to prevent cholangitis of the undrained lobe and to preserve liver function during the course of chemotherapy. Bilateral biliary drainage can be accomplished by the percutaneous or endoscopic placement of multiple self-expandable metallic stents (SEMS). Although SEMS placement via bilateral (multiple) percutaneous routes is technically simple, multiple percutaneous transhepatic biliary drainage (PTBD) may lead to additional morbidity. SEMS placement via a single percutaneous route is a useful method; however, negotiation of a guidewire into the contralateral bile duct is occasionally impossible if the hilar angle between the right hepatic duct and left hepatic duct is acute. Percutaneous dual SEMS placement is generally performed using the stent-in-stent technique (T configuration or Y configuration) or the side-by-side technique. In addition, the crisscross technique has been reported as being a useful method for trisegmental drainage. The side-to-end technique is also useful for multiple SEMS placement. In the future, the combination of percutaneous intervention and endoscopic ultrasonography-guided procedures may be effective in the management of malignant hilar biliary obstruction.

Purpose: To evaluate posthepatectomy liver failure (PHLF) using gadoxetic acid-enhanced magnetic resonance imaging (MRI) with a measure of relative liver enhancement (RLE) on hepatobiliary phase images, thereby facilitating safe liver resection. Methods: Twenty patients in Child-Pugh class A underwent tumor excision surgery and indocyanine green (ICG) clearance of future remnant liver (FRL) (ICG-Krem) values were >0.05. PHLF was evaluated using the grading system of the International Study Group of Liver Surgery (ISGLS). The RLE value was defined as the signal gain percentage between the precontrast and hepatocellular images. In the whole liver and FRL, theRLE value measured the tumor-free liver parenchyma in RLE images. We examined the correlation between indocyanine green clearance (ICG-K) and MRI-based liver function in the whole liver. Preoperative PHLF evaluation was predicted using remnant hepatocellular uptake index (rHUI), remnant RLE (rRLE), coefficient variation of Rrle [Cv(rRLE)], and ICG-Krem corrected by heterogeneous liver function(HLF-ICG-Krem). Results: HLF-ICG-Krem and rRLE values correlated with INRs after postoperative day five (r = -0.55 and 0.46, p = 0.01 and 0.04, respectively). Furthermore, HLF-ICG-Krem values ≤0.05 detected two patients with higher INRs after postoperative day five. On the other hand, neither rHUI nor Cv(rRLE) was correlated with INRs after postoperative day five (r = 0.28, and -0.03, respectively; p >0.05 for both). HLF-ICG-Krem was significantly lower with PHLF than without PHLF (p = 0.005). Conclusion: HLF-ICG-Krem is useful for evaluating PHLF more correctly.

Purpose To evaluate the safety and efficacy of a mixture of indigo carmine and lipiodol (MIL) as a marker of pulmonary nodule before video-assisted thoracic surgery (VATS). Materials and Methods One hundred sixty-eight sessions of pulmonary marking were performed using MIL before VATS for 184 nodules (mean size, 1.2 ± 0.6 cm; range, 0.3–3.6 cm) on 157 patients (83 men and 74 women; median age, 66 years). The mean distance between the lung surface and the nodule was 0.8 ± 0.7 cm (range, 0–3.9 cm). MIL was injected near the nodule using a 23-gauge needle. Mean number of 1.2 ± 0.4 (range, 1–3) punctures were performed in a session for the target nodules, with mean number of 1.1 ± 0.3 (range, 1–3). Successful targeting, localization, and VATS were defined as achievement of lipiodol accumulation at the target site on computed tomography, detection of the nodule in the operative field by fluoroscopy or visualization of dye pigmentation, and complete resection of the target nodule with sufficient margin, respectively. Results The successful targeting rate was 100%, and the successful localization rate was 99.5%, with dye pigmentation for 160 nodules (87.0%) and intraoperative fluoroscopy for 23 nodules (12.5%). Successful VATS was achieved for 181 nodules (98.4%). Two nodules (1.1%) were not resectable, and surgical margin was positive in 1 nodule (0.5%). Complications requiring interventions occurred in 5 sessions (3.0%) and included pneumothorax with chest tube placement (n = 3) and aspiration (n = 2). No complication related to the injected MIL occurred. Conclusions MIL was safe and useful for preoperative pulmonary nodule marking.

Purpose To investigate the feasibility of percutaneous drainage via the blind end of the jejunal limb (BEJL) for afferent limb syndrome and pancreatic fistula. Materials and Methods Percutaneous drainage via the BEJL was performed in eight patients (seven men and one woman; mean age, 63 y; range, 42–71 y) presenting with afferent limb syndrome (n = 6) or pancreatic fistula (n = 2) following pancreatoduodenectomy or bile duct resection with reconstruction at our institute from March 2005 to June 2013. Reconstruction was performed by using a modified Child method or the Roux-en-Y method, and the BEJL was surgically fixed to the abdominal wall. Afferent limb syndrome was caused by tumor recurrence or postoperative complications. Technical success, clinical success, and complications were evaluated retrospectively. Results Technical success of drainage via BEJL was achieved in all patients. Drainage catheters (5–10 F) were inserted into the afferent limbs of six patients, into the pancreatic duct of one patient, and into the pancreatic fistula of one patient. Metallic stents were subsequently placed to address malignant afferent limb obstruction in two patients. Clinical success was achieved in seven patients (87.5%), and no patients developed major complications. Drainage catheters were removed from four patients. The mean catheter indwelling period in all patients was 143 days (range, 21–292 d). Conclusions Percutaneous drainage via BEJL after pancreatoduodenectomy or bile duct resection may be a feasible treatment for afferent limb syndrome and pancreatic fistula.

Purpose To visualize liver uptake function using the uptake contrast-enhanced ratio in hepatobiliary phase (uptake CERH) magnetic resonance imaging. Materials and methods Thirty-seven patients with hepatocellular carcinoma (HCC) and 23 with metastatic liver cancer were evaluated. Hepatobiliary phase images were acquired 20 min after an intravenous bolus injection of gadoxetic acid disodium. We assumed that the contrast-enhanced ratio in the hepatobiliary phase (CERH) in the spleen was similar to the contrast-enhanced ratio in the extracellular matrix (CEREM). The Uptake CERH value was defined as the percentage signal gain between the precontrast and hepatobiliary phase images (without CEREM). The Uptake CERH value measured the tumor-free liver parenchyma. The association of the uptake CERH value with the biochemical liver function test results, and hepatocellular density in the liver parenchyma was assessed. Correlations were examined using Pearson correlation coefficient and the Mann–Whitney test. Results The uptake CERH value was correlated with albumin, bilirubin, indocyanine green retention rate at 15 min, prothrombin activity(%), platelet count, and cellular density in the liver parenchyma (p Conclusions Uptake CERH images are useful for visualizing liver uptake function.

Adenosquamous carcinoma of the pancreas (ASC) is a rare malignant neoplasm of the pancreas, exhibiting both glandular and squamous differentiation. However, little is known about its imaging features. This study examined the imaging features of pancreatic ASC.We evaluated images of contrast-enhanced computed tomography (CT) and endoscopic ultrasonography (EUS). As controls, solid pancreatic neoplasms matched in a 2:1 ratio to ASC cases for age, sex and tumor location were also evaluated.Twenty-three ASC cases were examined, and 46 solid pancreatic neoplasms (43 pancreatic ductal adenocarcinomas, two pancreatic neuroendocrine tumors and one acinar cell carcinoma) were matched as controls. Univariate analysis demonstrated significant differences in the outline and vascularity of tumors on contrast-enhanced CT in the ASC and control groups (P 0.001 and P 0.001, respectively). A smooth outline, cystic changes, and the ring-enhancement pattern on contrast-enhanced CT were seen to have significant predictive powers by stepwise forward logistic regression analysis (P = 0.044, P = 0.010, and P = 0.001, respectively). Of the three, the ring-enhancement pattern was the most useful, and its predictive diagnostic sensitivity, specificity, positive predictive value and negative predictive value for diagnosis of ASC were 65.2%, 89.6%, 75.0% and 84.3%, respectively.These results demonstrate that presence of the ring-enhancement pattern on contrast-enhanced CT is the most useful predictive factor for ASC.

OBJECTIVE Percutaneous endoscopic gastrostomy is widely practiced, but we use interventional radiology techniques to perform percutaneous radiologic gastrostomy in cancer patients with conditions that prevent endoscope insertion due to pharyngoesophageal obstruction. This study retrospectively investigated the effectiveness of percutaneous radiologic gastrostomy at our hospital. METHODS We investigated the medical records of 105 patients who underwent percutaneous radiologic gastrostomy between 2001 and 2011. The technique used for percutaneous radiologic gastrostomy comprised insufflation to dilate the stomach via a nasogastric tube, followed by fluoroscopically guided puncture and gastrostomy tube placement. In patients for whom a nasogastric tube could not be inserted, the stomach was punctured with a fine needle under ultrasonographic guidance and insufflated via this puncture needle to achieve dilation. RESULTS Patients comprised 75 men and 30 women (mean age, 63 years). A nasogastric tube was used during percutaneous radiologic gastrostomy in 81 cases, but could not be used in 24. The percutaneous radiologic gastrostomy procedure was successful in all cases. Serious post-percutaneous radiologic gastrostomy complications comprised one case each of decreased hemoglobin requiring blood transfusion, pneumoperitonitis that was treated by a laparotomy and infected fistula requiring tube removal (3/105, 2.9%). Duration of gastrostomy tube placement was 1-731 days, and the outcome was death in 59 cases, hospital transfer in 23, tube removal in 18 and survival with gastrostomy tube in place in 5. CONCLUSIONS Serious complications requiring treatment occurred in 2.9% of cases in which percutaneous radiologic gastrostomy was performed, with mostly good effectiveness. Percutaneous radiologic gastrostomy is feasible even for patients in whom a nasogastric tube cannot be inserted.

This study aimed to identify the computed tomography characteristics of treatment-naive patients with lung adenocarcinoma and known driver mutations in EGFR, KRAS, or ALK. Patients with advanced lung adenocarcinoma (stage IIIB–IV) and known mutations in EGFR, KRAS, or ALK were assessed. The radiological findings for the main tumor and intra-thoracic status were retrospectively analyzed in each group, and the groups’ characteristics were compared. We identified 265 treatment-naive patients with non-small-cell carcinoma, who had EGFR mutations (n = 159), KRAS mutations (n = 55), or ALK rearrangements (n = 51). Among the three groups, we evaluated only patients with stage IIIB–IV lung adenocarcinoma who had EGFR mutations (n = 126), KRAS mutations (n = 35), or ALK rearrangements (n = 47). We found that ground-glass opacity at the main tumor was significantly more common among EGFR-positive patients, compared to ALK-positive patients (p = 0.009). Lymphadenopathy was significantly more common among ALK-positive patients, compared to EGFR-positive patients (p = 0.003). Extranodal invasion was significantly more common among ALK-positive patients, compared to EGFR-positive patients and KRAS-positive patients (p = 0.001 and p = 0.049, respectively). Lymphangitis was significantly more common among ALK-positive patients, compared to EGFR-positive patients (p = 0.049). Pleural effusion was significantly less common among KRAS-positive patients, compared to EGFR-positive patients and ALK-positive patients (p = 0.046 and p = 0.026, respectively). Lung metastases were significantly more common among EGFR-positive patients, compared to KRAS-positive patients and ALK-positive patients (p = 0.007 and p = 0.04, respectively). In conclusion, EGFR mutations were associated with ground-glass opacity, KRAS-positive tumors were generally solid and less likely to metastasize to the lung and pleura, and ALK-positive tumors tended to present with lymphadenopathy, extranodal invasion, and lymphangitis. These mutation-specific imaging characteristics may be related to the biological differences between these cancers.

A phase II study of stent therapy for unresectable malignant colorectal obstruction was conducted to ascertain the clinical efficacy, safety, and procedural feasibility.Inclusion criteria comprised unresectable obstruction of the rectum or sigmoid colon; no other apparent stenosis; performance status by Eastern Cooperative Oncology Group ≤3; and maintained major organ function. The treatment protocol was to place an uncovered metal stent through the anus in an obstructive portion under x-ray fluoroscopic guidance. The patients were followed for 4 weeks after therapy, and the degree of improvement in subjective symptoms lasting ≥2 weeks was assessed as effective when the patient was decompressed with stent, or ineffective when not decompressed. Rate of clinical efficacy was defined as the proportion of effective cases.The participants of the study comprised 33 patients (13 men and 20 women; mean age, 60 y). Rate of procedure completion was 97.0% (32/33). Treatment was effective in 27 patients, ineffective in 4, and unassessable in 1, yielding a clinical efficacy rate of 81.8% (27/33). Death owing to underlying disease (n=3), stent removal owing to anal pain (n=1), and occlusion at another location (n=1) were noted. No recurrences were seen among clinically effective cases. Adverse reactions included grades 2 to 3 diarrhea (n=12), pain (n=5), bleeding (n=1), and dysuria (n=1), but no grade 4 adverse reactions or treatment-related deaths were identified.Stent therapy for unresectable malignant colorectal obstruction is effective, safe, and feasible.

The aim of this study was to evaluate the association of sensitivity to previous irinotecan-based chemotherapy with efficacy of cetuximab plus irinotecan therapy in metastatic colorectal cancer (MCRC) patients with wild-type KRAS. We analysed a pooled data set consisting of data from 87 MCRC patients from two previous phase II studies (n=60) and a group given off-protocol treatment (n=27) following irinotecan-, oxaliplatin-, and fluoropyrimidine-based chemotherapy. Overall objective response rate to cetuximab plus irinotecan was 28.7%, median progression-free survival (PFS) was 5.3 months, and median overall survival was 12.2 months. Objective response rate did not significantly differ between patients with a favourable response to previous irinotecan (n=23), stable disease (n=38), or progressive disease (n=26), with observed rates of 29.2%, 31.6%, and 23.1%, respectively. Additionally, the non-parametric Spearman rank correlation coefficients (ρ) between the PFS of previous irinotecan-based chemotherapy and that of cetuximab plus irinotecan were quite low (ρ=0.067 and 0.057 in patients with previous irinotecan as first- and second-line therapies, respectively). Although exploratory nature and small sample size may be limitations of this study, these findings indicate that the efficacy of irinotecan plus cetuximab in MCRC patients with wild-type KRAS did not differ by previous sensitivity to irinotecan.

The efficacy and safety of cetuximab for irinotecan-intolerant patients has not yet been evaluated in detail. We retrospectively analyzed the efficacy and safety of cetuximab monotherapy for patients with metastatic colorectal cancer (MCRC) that was intolerant to irinotecan. Among 105 patients who received cetuximab-containing chemotherapy until March 2010, 22 patients were treated with cetuximab monotherapy due to irinotecan intolerance. Cetuximab was given at the approved dosage to all patients. The performance status was 2 or 3 in 17 patients (77%). All but 1 patient had wild-type KRAS tumors. The causes of irinotecan intolerance were icterus (n = 9; 41%; median serum total bilirubin, 6.3 mg/dl), symptomatic peritoneal metastasis or obstruction (n = 8; 36%), and thrombocytopenia (n = 1; 5%). Four patients (18%) refused irinotecan due to previous irinotecan-associated toxicity. Two patients achieved a partial response with an apparent drop of serum bilirubin, for a response rate of 9.1%. The median progression-free survival and overall survival were 1.6 and 3.5 months, respectively. No grade 3 or 4 adverse events or treatment-related deaths were experienced. Cetuximab monotherapy for irinotecan-intolerant MCRC is feasible. However, the overall efficacy was modest in the present cohort, despite the fact that most of the patients had wild-type KRAS tumors; further effective therapies should be evaluated to improve the prognosis of this patient population.

No established therapy exists for unresectable intrahepatic cholangiocarcinoma (ICC). We conducted a phase I/II study to ascertain the recommended dose (RD) of hepatic arterial infusion using gemcitabine (GEM) for ICC and to assess the efficacy and safety.For patients with unresectable ICC, GEM was administered through the hepatic artery via the port system as a 30-minute infusion on days 1, 8, and 15 every 4 weeks for 5 cycles. In phase I, dosage for levels 1, 2, and 3 was set at 600, 800, and 1000 mg/m, respectively, and was increased in 3 to 6 patients at a time. Maximum tolerated dose was defined as a dosage resulting in dose-limiting toxicity in 2 of 3 patients or 3 of 6 patients, and RD was estimated during the first cycle. In the phase II, more RD patients were added to assess tumor response and toxicity.During the phase I, 16 patients were enrolled. Maximum tolerated dose was not reached. Assuming RD at 1000 mg/m, the phase II enrolled a total of 13 patients. The following Grade 3 toxicities were observed: neutropenia 20%, increased gamma-glutamyl transpeptidase 8%, increased aspartate aminotransferase 4%, increased alanine aminotransferase 4%, increased bilirubin 4%, nausea 4%, and fatigue 4%. The tumor response rate was 7.7% (complete response 0, partial response 1, stable disease 8, and progressive disease 4).Whereas the toxicity of hepatic arterial infusion with 1000 mg/m GEM for ICC was tolerable, expected efficacy could not be obtained, thus suggesting only minimal activity.

Background: The ability of molecular targeting agents to improve overall survival (OS) in metastatic colorectal cancer (MCRC) patients who underwent oxaliplatin-based chemotherapy remains controversial. Methods: We retrospectively analyzed 331 patients with MCRC who underwent first-line oxaliplatin-based chemotherapy. Treatment outcomes were compared between patients who started chemotherapy from April 2005 to March 2007 (cohort A; n = 157) and those who started it from April 2007 to March 2009 (cohort B; n = 174). To evaluate the impact of exposure to agents, we applied time-varying covariate analysis to avoid possible lead-time bias. Results: Median OS of cohorts A and B was 21.3 and 28.6 months, respectively (HR 0.66, 95% CI 0.50–0.87, p = 0.003). Exposure to bevacizumab (25 vs. 76%), anti-epidermal growth factor receptor (EGFR) (18 vs. 33%) or curative surgery after chemotherapy (4 vs. 10%) was significantly higher in cohort B. According to a multivariate Cox model with exposure to each agent or treatment as a time-varying covariate, hazard ratios of death were 0.71 (95% CI, 0.51–0.96; p = 0.03) for bevacizumab, 0.62 (95% CI, 0.40–0.89; p = 0.01) for anti-EGFR and 0.22 (95% CI, 0.06–0.57; p = 0.004) for surgery. Conclusions: Increased exposure to molecular targeting agents or surgery after chemotherapy appears to contribute to an improvement in OS in recent patients with MCRC who have undergone oxaliplatin-based chemotherapy.

Complete esophageal obstruction developed after radiation and endoscopic submucosal dissection therapy for a cervical esophageal cancer in a 77-year-old woman. After failure to recanalize the esophageal obstruction by endoscopic and catheterization techniques, the esophageal obstruction was penetrated using a trocar stylet needle via a gastrostomy route. A covered stent was placed across the esophageal obstruction, letting her take water and liquid food until she died 2 months later. There was no complication related to the procedures except transient chest discomfort and pain that subsided with symptomatic treatment.

We retrospectively evaluated the safety and efficacy of preoperative initial hepatic arterial infusion chemotherapy (HAIC) through a port-catheter system in patients with liver dysfunction due to synchronous and unresectable liver metastases. The aim of HAIC was to improve patients' clinical condition for later surgical removal of primary colorectal cancer.Port-catheter systems were placed radiologically in 21 patients (mean age 58.6 +/- 8.1 years) with liver dysfunction due to synchronous liver metastases from colorectal cancer. Initial HAIC of 1,000 mg/m(2) 5-fluorouracil was administered weekly as a 5 hr continuous infusion through this system. Surgical removal of the primary lesion was planned after HAIC improved the liver function.Port-catheter system placement was successful in all patients without severe complications. Patients were followed up for a median of 309 days (range 51-998 days). After starting HAIC, no severe adverse events that caused drug loss and treatment postponement or suspension were observed in any of the patients. HAIC was performed a mean of 4.5 +/- 3.0 times and the liver function improved in all patients. Curative (n = 18) or palliative (n = 1) surgical removal of the primary lesion was performed. The remaining 2 patients died because extrahepatic metastases developed and their performance status worsened; thus, surgery could not be performed. The median survival times of all patients and the operated patients were 309 and 386 days, respectively.Initial HAIC administration is a safe and efficacious method for improving liver function prior to operative resection of primary colorectal cancer in patients with liver dysfunction due to synchronous and unresectable liver metastases.

A resected case of hepatocellular carcinoma which extended into the right atrium after treatment with hepatic arterial infusion chemotherapy (HAIC) is described. An 81-year-old man presented with right hypochondralgia. CT demonstrated a hypervascular tumor 11.5 cm in diameter extending into the right atrium through the right hepatic vein. The patient underwent HAIC with 100 mg of cisplatin (CDDP IA-call®) particles three times every month. The tumor showed a marked shrinkage and an involution of the venous thrombus around the orifice of the right hepatic vein. Right hemihepatectomy with tumor thrombectomy was performed as a salvage surgery using a total hepatic vascular exclusion technique. Histologically, the tumor turned into diffuse necrosis and fibrosis, so viable tumor cells were encountered neither in the main tumor nor venous thrombus. The therapeutic effect of HAIC was pathological complete remission. The patient has been doing well for 6 years after the surgery without evidence of tumor recurrence. The salvage operation was safely achievable for the initially unresectable advanced hepatocellular carcinoma extending into the right atrium.

Sentinel lymph node biopsy (SLNB) is an important technique for detecting axillary lymph node metastasis in breast carcinoma patients. However, false-negative results are a problem. Equivalent cross-relaxation rate (ECR) imaging (ECRI) is a measurement method that can be used to quantitatively evaluate a change in the structural organization of lymph nodes by magnetic resonance imaging (MRI). We performed axillary ECRI in an attempt to decrease the false-negative results of SLNB. Regions without metastases showed a higher ECR value. On the other hand, regions with metastases showed a lower ECR value. The ECR images were compared with macroscopic histology images in which the presence or absence of axillary lymph node metastasis could be evaluated. ECRI is a potentially useful method for evaluating the efficacy of SLNB.

Acute hyperammonemic encephalopathy induced by fluoropyrimidines (FPs) is a rare complication. Its pathophysiology remains unclear, especially given the currently used regimens, including intermediate-doses of 5-fluorouracil (5-FU) or oral FP agents. We aimed to characterize the clinical manifestations in cancer patients who developed hyperammonemic encephalopathy after receiving FP-based chemotherapy.We retrospectively reviewed 1786 patients with gastrointestinal or primary-unknown cancer who received FP-based regimens between 2007 and 2012. Eleven patients (0.6%) developed acute hyperammonemic encephalopathy. The incidence according to the administered anticancer drugs were as follows: 5-FU (8 of 1176, 0.7%), S-1 (1 of 679, 0.1%), capecitabine (2 of 225, 0.9%), and tegafur-uracil (UFT) (0 of 39, 0%). Ten patients (90.9%) had at least 1 aggravating factor, including infection, dehydration, constipation, renal dysfunction, and muscle loss. All the 10 patients met the definition of sarcopenia. Median time to the onset of hyperammonemic encephalopathy in the cycle was 3 days (range: 2-21). Three patients (27.3%) developed encephalopathy during the first cycle of the regimen and the remaining 8 patients during the second or more cycles. Seven patients (63.6%) had received at least 1 other FP-containing regimen before without episodes of encephalopathy.All patients recovered soon after immediate discontinuation of chemotherapy and supportive therapies, such as hydration, infusion of branched-chain amino acids, and oral lactulose intake, with a median time to recovery of 2 days (range

Although systemic multidrug chemotherapy is the first-line therapy for unresectable colorectal cancer, hepatic arterial infusion chemotherapy(HAI)may be a potential alternative treatment for patients with unresectable colorectal liver metastasis. A 65-year-old man underwent sigmoidectomy for sigmoid colon cancer with bilobar, multiple liver metastases. Postoperatively, an HAI regimen of 5-fluorouracil(5-FU, 1,000mg/m²/5 h/every week)was administered for 26 weeks; the total dose of 5-FU administered was 52 g. Complete response(CR)was achieved, according to an imaging diagnosis technique. Thereafter, the patient was followed-up in an outpatient setting, without any further anti-cancer treatment. A solitary liver metastasis was identified by using magnetic resonance imaging(MRI), 6 years 6 months after achieving CR. The patient underwent partial liver resection for the recurrent liver metastasis. Histological diagnosis revealed an adenocarcinoma, consistent with the findings for metastatic sigmoid colon cancer. The patient's postoperative recovery was uneventful, and he remains alive 5 years after liver resection, without any evidence of tumor recurrence. Further long-term follow-up might be advisable considering the slow-growing nature of this tumor.

OBJECTIVE To retrospectively evaluate relative enhancement (RE) in the hepatobiliary phase of gadoxetic acid disodium-enhanced magnetic resonance (MR) imaging as a preoperative estimation of future remnant liver (FRL) function in a patients who underwent portal vein embolization (PVE). MATERIALS AND METHODS In 53 patients, the correlation between the indocyanine green clearance (ICG-K) and RE imaging was analyzed before hepatectomy (first analysis). Twenty-three of the 53 patients underwent PVE followed by a repeat RE imaging and ICG test before an extended hepatectomy and their results were further analyzed (second analysis). Whole liver function and FRL function were calculated on the MR imaging as follows: RE x total liver volume (RE Index) and FRL-RE x FRL volume (Rem RE Index), respectively. Regarding clinical outcome, posthepatectomy liver failure (PHLF) was evaluated in patients undergoing PVE. RESULTS Indocyanine green clearance correlated with the RE Index (r = 0.365, p = 0.007), and ICG-K of FRL (ICG-Krem) strongly correlated with the Rem RE Index (r = 0.738, p < 0.001) in the first analysis. Both the ICG-Krem and the Rem RE Index were significantly correlated after PVE (r = 0.508, p = 0.013) at the second analysis. The rate of improvement of the Rem RE Index from before PVE to after PVE was significantly higher than that of ICG-Krem (p = 0.014). Patients with PHLF had a significantly lower Rem RE Index than patients without PHLF (p = 0.023). CONCLUSION Relative enhancement imaging can be used to estimate FRL function after PVE.

Pneumothorax is a common complication following transthoracic interventional procedures. Most often, this occurs unilaterally on the side of the intervention. Bilateral pneumothorax following unilateral puncture is rare, but may mandate emergent chest tube insertion. We describe two cases in which bilateral pneumothorax occurred after unilateral thoracic puncture. One patient had a history of esophageal resection, while the other had no history of thoracic surgery.