Visualization of pancreaticobiliary reflux in anomalous pancreaticobiliary junction by secretin-stimulated dynamic magnetic resonance cholangiopancreatography

PURPOSE

To assess the utility of secretin-stimulated dynamic MR cholangiopancreatography (MRCP) for the visualization of pancreaticobiliary reflux in patients with anomalous pancreaticobiliary junction (PBJ).

MATERIAL AND METHODS

Ten controls and seven patients diagnosed as having anomalous PBJ were prospectively examined by dynamic MRCP after secretin injection using a breath-hold, single-shot turbo spin-echo T2-weighted sequence. The optimal MRCP section was repeated 35 times at approx. 10-second interval after secretin injection; the acquisition time was 4 s per image. The signal intensity (SI) changes of the extrahepatic and intrahepatic bile ducts, presence or absence of intraluminal signal void, caliber change of the bile duct, duodenal filling, and peak time of the SI ratio of the extrahepatic bile duct after secretin injection were compared between the controls and patients.

RESULTS

In the controls, the extrahepatic and intrahepatic bile ducts showed neither enhancement nor caliber change over the observation period, providing no apparent peak time. Of the seven patients, the extrahepatic bile duct showed retrograde enhancement and sequential delay in occurrence of the peak time from its distal third to its proximal third (n = 6) with a signal void in its distal part (n =4); its caliber increased subsequently to pancreatic secretion (n = 5); the intrahepatic bile ducts showed a slight enhancement following SI increase of the proximal extrahepatic bile duct (n = 6); duodenal filling grade tended to be lower in the patients than volunteers (P<.005).

CONCLUSION

In patients with anomalous PBJ pancreaticobiliary reflux were demonstrated by dynamic secretin-stimulated MRCP.

Adult-onset leukoencephalopathy with vanishing white matter with a missense mutation inEIF2B5

We report of a woman aged 52 years born to consanguineous parents and seeking treatment for progressive dementia and delusion. Neurologic examination revealed dementia and emotional instability, indifference, and confabulation. There was also mild spasticity of the bilateral lower limbs. MRI revealed diffuse white matter hyperintensity on T2-weighted images accompanied by hypointense areas on fluid-attenuated inversion recovery images. A homozygous missense mutation was identified in EIF2B5.

Eclamptic encephalopathy: MRI, including diffusion-weighted images

Eclampsia is a rare condition peculiar to pregnant and puerperal women. We analyse imaging features in five patients with eclampsia, and determine whether diffusion-weighted imaging (DWI) could differentiate cytotoxic and vasogenic oedema in four of them. All were imaged within 4 days of the onset of symptoms. We found lesions with a prolonged T2 in the brain of all five patients, in the basal ganglia in four, pons in three and posterior cerebral white matter in two. Isotropic DWI revealed variable intensity in these regions. The ADC was decreased in one, and increased in all the others. The lesion with reduced ADC progressed to infarction.

[Efficacy of continuous hepatic arterial infusion of high-dose 5-FU for liver metastases of gastric cancer]

We studied the efficacy of continuous hepatic arterial infusion of high-dose 5-FU (high-dose CHAI) in two patients with multiple (five or more) bilobar liver metastases of gastric cancer. 5-FU was given continuously via the hepatic artery at 1 g/day for 3 days, followed by one day off therapy and repetition of the initial treatment as one course. Case 1 was a 67-year-old man with Borrmann type 2 gastric cancer who had undergone total gastrectomy. Metachronous multiple liver metastases (maximum diameter: 3.5 cm) were detected at 11 months after surgery. One month later, we started high-dose CHAI and gave two courses with a 4-day interval between them. After that, 5-FU was given twice by hepatic arterial infusion (HAI) at dose of 1.5 g/week. The tumor diameter had decreased by 50% at 3 months after high-dose CHAI. Case 2 was a 64-year-old man with Borrmann type 3 gastric cancer who had synchronous multiple liver metastases (maximum diameter: 9 cm) and liver dysfunction. One month after distal gastrectomy, we started high-dose CHAI and finished one course. After that, liver function returned to normal and 5-FU was given by HAI at dose of 1 g/week on an outpatient basis. The tumor diameter decreased to 1/3 of the initial size at four months after high-dose CHAI. High-dose CHAI using 5-FU may be safe and effective for liver metastases from gastric cancer.

Power Doppler sonography of hepatocellular carcinoma treated by transcatheter arterial chemoembolization. Assessment of the therapeutic effect

PURPOSE

To evaluate the usefulness of power Doppler sonography (PDS) in assessing the therapeutic effect of transcatheter arterial chemoembolization (TACE) in hepatocellular carcinoma (HCC).

MATERIAL AND METHODS

TACE was performed in 43 patients (48 lesions) with HCC. All patients were examined with both PDS and color Doppler sonography (CDS) to assess the therapeutic results 1 week after TACE. Follow-up hepatic angiography was performed in 39 patients 3-4 months after TACE and then CT after iodized oil reinjection was also performed 3-4 weeks after a repeat TACE; in the remaining 4 patients, hepatectomy was performed within one month after chemoembolization and histologic study was undertaken to confirm the Doppler findings.

RESULTS

Determination of therapeutic results with PDS and CDS were in agreement with those of follow-up findings in 37 and 29 of the 48 lesions, respectively. There was a significant difference in overall accuracy (p=0.038) between PDS and CDS results.

CONCLUSION

PDS is more effective than CDS for evaluating changes in tumor vascularity after TACE. PDS may also replace angiography in assessing the therapeutic effects of TACE for HCCs, except in deep-seated areas.

[A case report: successful resection of advanced intrahepatic cholangiocarcinoma responding to preoperative hepatic artery infusion of 5-FU]

A patient with advanced intrahepatic cholangiocarcinoma had a tumor embolus in the right main branch of the portal vein and lymph node metastases. Hepatic arterial infusion (HAI) therapy with 5-FU (1 g/day) was given as a continuous infusion for 6 days. The treatment was repeated after a one-week interval. As a result the tumor diameter decreased by half, and the tumor embolus contracted. Cytoreductive surgery was then performed. The patient has been disease-free for over 9 months postoperatively with adjuvant HAI with 5-FU. We consider preoperative HAI with 5-FU (two courses of 1 g/day x 6 days) is both safe and effective.

[Results of clinical study with epirubicin hydrochloride injectable solution in hepatoma]

A 10-center cooperative clinical study with a new formulation of epirubicin hydrochloride injectable solution (Epirubicin-RTU) was conducted in patients with hepatocellular carcinoma. Epirubicin-RTU 60 mg/m2 was injected into the hepatic artery and a three-week drug-free interval followed. Of 15 patients with hepatocellular carcinoma registered in this study, 14 patients were eligible, and they all completed the entire course. The objective was to investigate the safety of treatment with Epirubicin-RTU in 14 eligible patients. The adverse drug reactions frequently observed in these 14 eligible cases were leukopenia, neutropenia, thrombocytopenia, alopecia, and fever. They were all reversible and tolerable. With these results. Epirubicin-RTU was considered to be a safe pharmaceutical product to inject into the hepatic artery.

[Efficacy of combination therapy (hepatectomy and prophylactic arterial chemoinfusion) for liver metastases of colorectal cancer]

From 1979 to 1997, 146 patients had hepatectomy for metastases of colorectal cancer (curative B: 122; curative C: 24). We categorized the severity of liver metastases as follows, H1: one lobe; H2: bilateral but less than five, and H3: bilateral with five or more lesions. In H1 and H2 patients, we compared the survival rate after resection alone (including repeat hepatectomy) with that after combination therapy (resection and prophylactic arterial chemoinfusion of 12-24 g of 5-FU). In H1 patients, the 3-year survival rate of the resected group (n = 74) and combination group (n = 6) was 47.2 and 53.3, respectively. In H2 patients, the resected group (n = 16) and combination group (n = 7) had survival rates of 34.5 and 100%, respectively. In H1 cases, the 3-year recurrence rate in the remnant liver was 63.4 versus 16.7% and in H2 cases it was 58.0 versus 0%. H3 patients received one week of continuous prophylactic arterial chemoinfusion [total dose of 5-FU = 6 g]. All four patients in the H3 combination group are alive at 20, 13, 13, and 12 months after resection, while the median survival of the resection only group (n = 4) was 12.5 months. We suggest that our combination therapy may be applicable to all patients with liver metastases of colorectal cancer.

[A new two-part therapy for multiple bilobar liver metastases of colorectal cancer--treatment of one lobe with partial hepatectomy and the other with arterial chemotherapy]

We studied a new two-part therapy for patients of multiple (more than five) bilobar liver metastases from colorectal cancer, in which one lobe is treated with partial hepatectomy and the other with arterial chemotherapy. The patient was a 72-year-old woman who had undergone sigmoidectomy and partial hepatectomy on March 9, 1995, for advanced sigmoid cancer with liver metastasis. In December 1995, new foci were detected in the remaining liver. Intraoperative echography during reoperation revealed 6 foci in the right lobe, 2 in the left lobe and 1 in the caudate lobe. During reoperation, we performed partial hepatectomy at the left lobe metastases and microwave coagulation in the caudate lobe. A catheter was inserted into the right hepatic artery, and the right hepatic artery was ligated with the catheter. From 2 weeks after operation, CDDP (20 mg) and 5-FU (1,500 mg) were given weekly by infusion from the arterial root. As a result, the serum CEA level fell to 3.6 ng/ml on June 26, 1996, and 1.9 mg/ml on August 14, 1996. A right lobectomy would have been performed if no metastasis appeared in the remainder of the left lobe over a one-year period. However, no foci were detected on a CT scan on March 26, 1997. This new two-part therapy warrants detailed investigation for bilobar bilateral liver metastases of colorectal cancer.

Visualization of tumor vessels in hepatocellular carcinoma. Power Doppler compared with color Doppler and angiography

PURPOSE

To assess the visualization of tumor vessels in hepatocellular carcinoma (HCC) by power Doppler sonography.

MATERIAL AND METHODS

We examined 40 patients with 47 HCC lesions by means of power Doppler sonography and compared its visualization of tumor vessels with those of color Doppler and angiography.

RESULTS

In 38 (81%) of the 47 lesions, power Doppler sonography improved the visualization of tumor vessels compared with color Doppler sonography; in the remaining lesions no significant difference was noted. In lesions located within 7 cm in depth, there was no significant difference between power Doppler sonography and angiography. In 10 (83%) out of 12 small (< or = 2 cm in diameter) lesions and in 11 (85%) out of 13 hypovascular lesions, power Doppler sonography performed considerably better than angiography. In deeper-seated lesions, however, angiography was significantly superior to power Doppler sonography.

CONCLUSION

Power Doppler sonography is more sensitive in detecting the fine tumor vessels in most HCCs than color Doppler sonography. In addition, power Doppler sonography can replace angiography in evaluating tumor vascularity in HCCs except in lesions that are deep-seated or located near the heart. In these lesions, angiography can complement power Doppler sonography in demonstrating tumor vessels.

[Radiological diagnosis of viral encephalitis]

Most of viral encephalitis may demonstrate no specific change on CT and MR images. Brain swelling, edema, abnormal density (CT) and abnormal intensity (MR) can be detected in herpes simplex encephalitis and enterovirus encephalitis (coxsackie, echo, polio). The common finding on CT and MRI in patients with HIV encephalopathy are atrophy, leukomalacia. Progressive multifocal leukoencephalopathy (PML) shows multifocal oval or round white matter T2-hyperintensities on MR images. Subacute sclerosing panencephalitis (SSPE) may present slight changes in the subcortical and periventricular white matter, as well as basal ganglia. Progressive disorder makes widespread T1-low, T2-high intensity area and atrophy. MRI of acute disseminated encephalomyelitis (ADEM) shows multifocal subcortical hyper intense foci on T2-weighted studies. The deep white matter, brainstem, thalamus and cerebellum can be affected. Most of ADEM lesions resolve. Imaging findings of acute lymphocytic meningitis by echovirus and coxsackievirus are usually normal.

[MR angiography and MR cholangiopancreatography]

MR angiography is an adjunctive for noninvasive evaluation of blood vessels and MR cholangiopancreatography is for bile duct and pancreatic duct. Clinical applications of MR angiography has been focused mainly on head and neck and its applications to the abdomen are still limited. However, this technique has the good potential for the evaluation of portal vein system. MR cholangiopancreatography can depict bile ducts and pancreatic duct simultaneously and three-dimensionally. This technique can evaluate the causes of the lesion and its extent noninvasively. In this article the practical uses of MR angiography and MR cholangiography in the abdomen are discussed.

Limitation of transcatheter arterial chemoembolization using iodized oil for small hepatocellular carcinoma. A study in resected cases

The radiologic and histologic findings are presented of the resection of 14 small hepatocellular carcinomas (HCC), less than 2 cm in maximum diameter, after transcatheter arterial chemoembolization (TCE) using iodized oil. The effect of TCE on small HCC depended on the morphologic type of the tumors. When no extracapsular invasion of tumor cells occurred, TCE was extremely effective against encapsulated tumors. However, in nine of the 14 resected specimens, viable tumor cells remained in or around the tumor. The authors suggest that small HCC are not always curable with TCE alone and that a multi-disciplinary approach is necessary for patients with small HCC.

Limitation of transcatheter arterial chemoembolization using iodized oil for small hepatocellular carcinoma. A study in resected cases

The radiologic and histologic findings are presented of the resection of 14 small hepatocellular carcinomas (HCC), less than 2 cm in maximum diameter, after transcatheter arterial chemoembolization (TCE) using iodized oil. The effect of TCE on small HCC depended on the morphologic type of the tumors. When no extracapsular invasion of tumor cells occurred, TCE was extremely effective against encapsulated tumors. However, in nine of the 14 resected specimens, viable tumor cells remained in or around the tumor. The authors suggest that small HCC are not always curable with TCE alone and that a multi-disciplinary approach is necessary for patients with small HCC.

Computed tomographic arteriography of the liver using balloon occlusion

The article describes a new method for computed tomographic arteriography (CTA) of hepatocellular carcinoma (HCC) using a balloon occlusion catheter in 8 patients. Our dynamic study indicated that: 1) a bolus injection of contrast medium with our method of CTA (CTA-B) produced an attenuation difference between liver and tumor which was about double that obtained with standard methods for CTA, and 2) marked tumor-liver attenuation differences (above 20 HU) persisted for more than 60 s in CTA-B and for not more than 20 s with conventional methods for CTA. The results show that CTA-B is superior to standard methods in enabling multiple scans of the liver during greater and prolonged differential tumor enhancement after administration of a bolus of contrast medium. In conjunction with table incrementation, CTA-B allows scanning of the entire liver at the time of maximal contrast enhancement with two to three injections of contrast medium. Two patients complained of abdominal pain during balloon inflation. No other complications were observed.

Portal blood flow in congestive heart failure: pulsed duplex sonographic findings

Twenty-one patients with congestive heart failure were examined with duplex sonographic scanning of the portal vein. The Doppler sonographic findings were compared with those of healthy subjects, patients with chronic liver disease, and patients with Budd-Chiari syndrome. Increasing pulsatility of the Doppler signals was demonstrated in 11 patients with severe congestive heart failure. Two patients with severe congestive heart failure showed decreasing pulsatility of portal Doppler signals in response to therapeutic procedures. Portal flow patterns suggestive of severe congestive heart failure include a monophasic forward flow with peak velocity in ventricular diastole and gradual diminution of velocity throughout ventricular systole (n = 5), a reversed flow velocity in ventricular systole (n = 3), and vena cava-like biphasic forward velocity peaks during each cardiac cycle (n = 2). The time-velocity waveform shape of portal flow is, to a large degree, influenced by the mechanical events in the right side of the heart in severe congestive heart failure.

Slippery coaxial catheter system

A slippery coaxial, 3-F catheter device was developed for selective angiography, embolization, and infusion of chemotherapeutic agents. The device comprises three parts: an 0.018-inch, plastic-coated guide wire; a 3-F coaxial catheter; and a 6.5-F guiding catheter. Both the guide wire and coaxial catheter are coated with hydrophilic polymer, which becomes slippery when immersed in water. Experience with four patients indicates the new coaxial catheter device is capable of traversing tortuous vessels smoothly and safely, and it permits infusion of chemotherapeutic agents and 1-mm gelatin particles.

In vitro propagation of herbaceous peony (paeonia lactiflora pall.) by a longitudinal shoot-split method

A procedure for the clonal propagation ofPaeonia lactiflora Pall. cvs. Takinoyosooi and Sarah Bernhardt through shoot tip culture is described. Half strength Murashige and Shoog (1962) medium supplemented with 0.5 mg/l 6-benzylaminopurine plus 1 mg/l gibberellic acid promoted formation and growth of axillary buds. Continuous shoot multiplication was achieved by vertically splitting the shoot axis and subsequent division of elongated axillary shoots every 36 days. High frequency (57-100%) of rooting was obtained on paper-bridge liquid medium supplemented with 1 mg/l indole-3-butyric acid. Half of the rooted plantlets were established on porous soil. Thus, 700 and 300 plants of cv. Takinoyosooi and Sarah Bernhardt could be theoretically obtained from a single bud in one year.

Hepatic venous outflow obstruction: evaluation with pulsed duplex sonography

Pulsed Doppler sonography was performed in six patients with hepatic outflow obstruction (five with Budd-Chiari syndrome and one with hepatic venocclusive disease) to assess its usefulness in evaluating the altered hemodynamics in this disease. Doppler signals were obtained from the inferior vena cava (IVC) and from hepatic, collateral, and portal veins. Normally, the IVC and hepatic veins show phasic forward (toward the heart) flow. In Budd-Chiari syndrome, the blood flow in the IVC and hepatic veins was absent, reversed, turbulent, or continuous. These Doppler findings were thought to be characteristic of Budd-Chiari syndrome. The portal velocity was reduced (n = 4) or increased (n = 1). The former was considered typical of Budd-Chiari syndrome. In hepatic venocclusive disease the IVC and major hepatic veins showed normal phasic flow; flow velocity in the portal vein was increased. Doppler sonography was found to correlate well with therapeutic results and angiographic findings.

Transcatheter arterial embolization for metastatic liver tumors: a study in resected cases

We evaluated histologically the effect of transcatheter arterial embolization (TAE) in five metastatic liver tumors from gastrointestinal cancer, which were resected at surgery or removed at autopsy after TAE. TAE was carried out with cubes of gelatin sponge; in 2 cases, iodized oil was used as peripheral embolic material. Histological examination revealed three tumors to be completely necrotized. Approximately 80% of the remaining two tumors were necrotic. Our data suggest that TAE holds promise in the treatment of metastatic liver tumor from gastrointestinal cancer.

Use of meglumine iotroxate in the detection of liver tumors by computed tomography

Experience with contrast enhanced computed tomographic (CT) examinations of 13 patients with hepatic tumors using a new cholangiographic contrast material, meglumine iotroxate, is described. After infusion, small density differences between the tumor and liver were accentuated. In 11 cases postcontrast CT using meglumine iotroxate improved visualization of lesions compared with conventional pre-and postcontrast CT using urographic contrast material. Our results indicate that contrast enhanced CT using meglumine iotroxate is a promising alternative to conventional CT in the detection of hepatic tumors.

Dynamic computed tomography of isodense hepatocellular carcinoma

Dynamic computed tomography (CT) was performed on 11 patients with isodense hepatocellular carcinoma (hepatoma). Ten consecutive 3 s scans were performed within 30 s following the bolus injection of contrast medium. Except for the diffuse type, isodense hepatoma enhanced strongly in the arterial phase. The degree of enhancement declined in the portal phase. In the case of diffuse hepatoma, fine tumor nodules enhanced slightly, showing mottled patterns intermingled with low and high density areas in one patient. Time-density curves indicated that the tumor density increased rapidly in the arterial phase but decreased in the portal phase, approximating that of the surrounding liver. When CT is used as a screening method to detect hepatoma, the possibility of an isodense tumor should always be kept in mind. Dynamic CT is essential for the detection of isodense hepatoma as well as diffuse, small tumors. If simultaneous multilaminographic CT is available in the future, dynamic CT may be the best method to evaluate a suspected lesion.

Dynamic CT of pancreatic tumors

Dynamic computed tomography was performed on 19 patients with clinically diagnosed pancreatic and peripancreatic tumors. There were 10 patients with pancreatic cancer, three with inflammatory pancreatic masses, two with cystadenoma, one with insulinoma, and three with peripancreatic tumors. Computed tomography was performed with a Varian-V-360-3 scanner; scanning was for 30 consecutive sec at 3 sec intervals after the bolus injection of 50 ml of contrast medium into the antecubital vein. Dynamic computed tomography (CT) may be more useful than conventional contrast CT because it facilitates: (1) correct evaluation of tumor vascularity allowing a differential diagnosis; (2) location of the boundary between tumor and a nontumor tissue; (3) detection of small tumors; and (4) visualization of pancreatic invasion by peripancreatic tumors. In addition, contrast enhancement and the degree of vascular proliferation can be quantitatively assessed by analyzing time-density curves.

Dynamic computed tomography of hepatocellular carcinoma

Nineteen patients with clinically proven hepatocellular carcinoma were studied by dynamic computed tomographic (CT) scanning. Ten consecutive 3 sec scans were performed within 30 sec, providing uninterrupted data collection. Dynamic CT scanning was useful in recognizing tumor vascularity, multiple small tumors, isodense tumors on conventional CT scans, the capsule of an encapsulated hepatocellular carcinoma, arteriovenous shunts, and vascular pools. Time-density curves were useful in evaluating the hemodynamics of the tumors; these could be classified into three types according to differences in their enhancement patterns.