Sonography Guided Percutaneous Radiofrequency Ablation of Hepatocellular Carcinoma: Effect of Cooperative Training on the Pretreatment Assessment of the Operation's Feasibility

OBJECTIVE: The aim of this study is to investigate the effects of cooperative training on the pretreatment assessment of the feasibility to perform Ultrasonography (US) guided percutaneous radiofrequency ablation for patients afflicted with hepatocellular carcinoma. MATERIALS AND METHODS: In our prospective study, 146 patients with 200 hepatocellular carcinomas were referred for radiofrequency ablation after triage by hepatologists. Three radiologists with different levels of experience performed the planning US before (group I) and after (group II) cooperative training, to evaluate whether radiofrequency ablation was feasible. The feasibility rates considered eligible according to our criteria were evaluated. In addition, we analyzed the reasons for the lack of feasibility were analyzed. The interobserver agreement for the assessment of feasibility before and after training was also calculated. RESULTS: The overall feasibility rates for both groups was 73%. No significant difference in the feasibility rates was observed. The feasibility rates of each observer for group I were 71% (observer 1), 77% (observer 2) and 70% (observer 3) and those for group II were 73%, 76% and 69%, respectively. In the tumors (n = 164) considered ineligible, the two most common causes for refraining from performing radiofrequency ablation included non-visualization of the tumor (62%) and the absence of a safe route for the percutaneous approach (38%). We found moderate interobserver agreement for all observers before cooperative training and a good agreement after training. CONCLUSION: Although the cooperative training did not affect the feasibility rate of each observer, it improved the interobserver agreement for assessing the feasibility of performing US guided radiofrequency ablation, which may reduce unnecessary admission or delayed treatment.

Percutaneous Radiofrequency Ablation for Benign Nodules of the Thyroid Gland

PURPOSE: We wanted to evaluate the efficacy and safety of using ultrasound guided percutaneous radiofrequency ablation for the benign nodules of the thyroid gland. MATERIALS AND METHODS: We studied 148 patients with benign thyroid nodules (200 total nodules) that were confirmed histopathologically, and we performed ultrasound guided radiofrequency ablation. The radiofrequency ablation was done 1 to 5 times per one nodule, and follow-up ultrasonography was performed one to nineteen months after the ablation procedures. The physical changes and the decrease of volume of the nodules were evaluated, and the complications related to radiofrequency ablation were observed. RESULTS: The mean initial nodule volume was 0.01-95.61 ml (mean; 6.83+/-SD of 10.63 ml) and the nodule volume after radiofrequency ablation was decreased to 0.00-46.56 ml (mean; 1.83+/-SD of 4.69 ml). The mean volume reduction rate was 73.2%. Reduction of more than 50% was noted in 90% of all cases. For 180 nodules (90%), the decrease was 50% or more, in 20 nodules (10%), the decrease was 49% or less. On gray-scale ultrasonogram obtained after ablation, the echogenicity of the nodules changed to darker, and on the doppler-sonogram, the vascular flow within the nodules disappeared in all cases. Most patients complained pain during or right after the procedure, but the pain was transient and subsided after medication. Two patients developed hoarseness that was improved in 1 week and 2 months, respectively. CONCLUSION: Sonoguided percutaneous radiofrequency ablation can be one of the treatments for benign nodules of the thyroid gland.

Radiofrequency Thermal Ablation of Metastatic Liver Tumors: Usefulness of Combined Chemotherapy

PURPOSE: To assess the usefulness of radiofrequency (RF) thermal ablation with combined chemotherapy for the treatment of metastatic liver tumors. MATERIALS AND METHODS: A non-randomized, comparative study was performed in 21 patients with metastatic liver tumors. Inclusion criteria were that these should be less than five in number and less than 6 cm in diameter. Two groups were designed for comparison of the local and remote (new intrahepatic or extrahepatic) tumor control rate (Group A: RF alone, n=11; Group B: RF+combined chemotherapy, n=10). There was no significant difference in age, sex, and mass size between the two groups (p>0.05). All ablations were performed percutaneously with a 50W RF generator and 15G-needle electrode (RITA Medical System Inc.) under US guidance. In group B, six cycles of systemic chemotherapy were performed every month immediately after RF ablation. Follow-up CT scans were obtained within 24 hours of ablation and were compared with the findings of pre-ablation CT scanning. If an ablated lesion covered the mass without any residual enhancing foci, this was defined as complete ablation. Three and six months after ablation, local and remote tumor control rates were compared between the two groups (follow up: range 4 -17 (mean, 10.2) months. RESULTS: In group A, the local tumor control rate was 43.8% (7/16) and 31.2% (5/16) at 3 and 6 months follow-up, respectively, while in group B, the corresponding rates were both 75% (15/20). At three months, the difference in this rate between the two groups was not significantly different (p>0.05), but at 6 months there was significant difference (p<0.05). At 6 months follow-up, the remote tumor control rate for Group A and Group B was 27.3% (3/11) and 80.0% (8/10), respectively, reflecting a significant difference between the two groups (p<0.05). CONCLUSION: In patients with metastatic liver tumor, radiofrequency thermal ablation with combined chemotherapy may be superior to RF thermal ablation alone for both local and remote tumor control.

Three-phase Dynamic CT Findings of Liver Abscess:Related Factors with Multiple Layering Enhancement Pattern

PURPOSE: To determine the number of multiple alternating layers of liver abscess, and changes in this number, as revealed by spiral CT, and to ascertain which factors are related to changes occurring during the three phases of this modality. MATERIALS AND METHODS: Using three-phase spiral CT imaging we studied 26 cases of liver abscess (pyogenic:amebicm=23:3). The number of layers comprising the abscess, as seen on postcontrast CT scans, was determined during the arterial (30sec), portal (70sec), and delayed (220sec) phase, and all cases were assigned to one of two groups according to changes in the number of layers observed during the three phases. With regard to underlying disease, the two groups were compared in terms of the presence of abscess and of diabetes mellitus,CT interval (time from onset of symptoms to CT scanning), microbial agent (pyogenic vs. amebic), and the largest diameter of abscess as revealed by CT. RESULTS: Except in one case, three or four alternating layers [in 13(50%) and 7(27%) cases, respectively] were seen only during the arterial and portal phase. During each of the three phases-and especially the delayed phase, where it was present in 25 of cases (96%)-two alternating layers (2:2:2) was the most common pattern, with a 3:3:3 pattern occurring in one case. All 12 cases (46%) in the unchanging-layer group showed one of these two patterns. All changing-layer group cases (14;54%) demonstrated three or four layers during the arterial and portal phase but only two during the delayed phase. The CT interval was the only significantly different factor between the two groups. During the first week, the number of cases in the unchanging-layer group was much higher than in the changing-layer group (86%,14%), but during the second week this situation reversed (25%, 75%). CONCLUSION: Our study reveals that on three-phase dynamic CT images, a characteristic enhancement feature of liver abscesses is three or four layers during the arterial and portal phases, with reduction to two layers during the delayed phase. This change, as revealed by spiral CT, is rare during the week following the onset of symptoms, but common during the second week.

A Case of Jejuno-jejunal Intussusception in Henoch-Schonlein Purpura / 대한소아소화기영양학회지

Gastrointestinal involvement occurs in two thirds of children with Henoch-Schonlein purpura (HSP) and intussusception is by far the most common abdominal complication. Intussusception in HSP almost originates in the small bowel, which is in contrast with idiopathic intussusception. Earlier diagnosis and prompt treatment of intra-abdominal complications can reduce the mortality and ultrasound is the imaging modality of choice in evaluation the bowel manifestations of HSP. We report a case of jejuno-jejunal intussusception associated with HSP in a 5-year-old boy who presented with diffuse abdominal pain and vomiting after a few days of HSP onset. Abdominal ultrasound demonstrated intussusception in the jejunum with well defined target appearance because of the thickened intussusceptum, which disappeared on the computerized tomographic examination checked approximately 24 hours later. A brief review of literature was made.

Radiofrequency Thermal Ablation of Malignant Hepatic Tumors: Post-Ablation Syndrome

PURPOSE: To evaluate post-ablation syndrome after radiofrequency thermal ablation of malignant hepatic tumors. MATERIALS AND METHODS: Forty-two patients with primary (n=29) or secondary (n=13) hepatic tumors under-went radiofrequency thermal ablation. A total of 65 nodules ranging in size from 1.1 to 5.0 (mean, 3.1) cm were treated percutaneously using a 50W RF generator with 15G expandable needle electrodes. We retrospec-tively evaluated the spectrum of post-ablation syndrome including pain, fever(> or =38 C degrees), nausea, vomiting, right shoulder pain, and chest discomfort according to frequency, intensity and duration, and the findings were cor-related with tumor location and number of ablations. We also evaluated changes in pre-/post-ablation serum aminotransferase(ALT/AST) and prothrombin time, and correlated these findings with the number of abla-tions. RESULTS: Post-ablation syndrome was noted in 29 of 42 patients (69.0%), and most symptoms improved with conservative treatment. The most important of these were abdominal pain (n=20, 47.6%), fever (n=8, 19.0%), and nausea (n=7, 16.7%), and four of 42 (9.5%) patients complained of severe pain. The abdominal pain lasted from 3 hours to 5.5 days (mean; 20.4 hours), the fever from 6 hours to 5 days (mean; 63.0 hours). and the nau-sea from 1 hour to 4 days (mean; 21.0 hours). Other symptoms were right shoulder pain (n=6, 14.3%), chest discomfort (n=3, 7.1%), and headache (n=3, 7.1%). Seventeen of 20 patients (85%) with abdominal pain had a subcapsular tumor of the liver. There was significant correlation between pain, location of the tumor, and number of ablations. After ablation, ALT/AST was elevated more than two-fold in 52.6%/73.7% of patients, respectively but there was no significant correlation with the number of ablation. CONCLUSION: Post-ablation syndrome is a frequent and tolerable post-procedural process after radiofrequency thermal ablation. The spectrum of this syndrome provides a useful guideline for the post-ablation management.

Radiologic Findings of Renal Hemangioma: Report of Three Cases

Renal hemangioma is an uncommon benign tumor which usually causes painless or painful gross hematuria. Its preoperative diagnosis is extremely difficult or even impossible. We experienced three cases of renal hemangioma, located mainly at the pelvocalyceal junction or in the inner medulla. US demonstrated variable echogenecity, and CT revealed a lack of significant enhancement. Where there is gross hematuria in a young adult, especially when the renal mass located in the pelvocalyceal junction or inner medulla shows little enhancement on CT, renal heman-gioma should form part of the differential diagnosis.

Primary Hepatic leiomyosarcoma: A case Report

Primary hepatic leiomyosarcoma is a rare tumor, most frequently occurring in liver parenchyma. We recentlyencountered an exophytic hepatic leiomyosarcoma ; CT scans indicated an indistinct border, with the parenchyme ofthe liver and parenchymal beaking suggesting a primary hepatic mass. We present an unusual case of primaryleiomyosarcoma which showed exophytic growth.

Systemic Lupus Erythematosus: Abdominal Radiologic Findings

Systemic lupus erythematosus(SLE) is a systemic disease of unknown etiology. Its main pathology is vasculitis and serositis, due to deposition of the immune complex or antibodies. Most findings are nonspecific ; abdominal manifestations include enteritis, hepatomegaly, pancreatic enlargement, serositis, lymphadenopathy, splenomegaly,nephritis, interstitial cystitis, and thrombophlebitis. We described radiologic findings of various organinvolvement of SLE; digestive system, serosa, reticuloendothelial system, urinary system, and venous system.Diagnosis of SLE was done according to the criteria of American Rheumatism Association. Understanding of thevariable imaging findings in SLE may be helpful for the early detection of abdominal involvement andcomplications.

Radiofrequency Thermal Ablation of Hepatic Tumors / 대한간학회지

No abstract availalbe

The Usefulness of Levin Tube Inserted Drip Infusion Spiral CT: Comparison with Conventional Method in SubtotalGastrectomy Patients

PURPOSE: To access the usefulness of newly designed Leven tube inserted drip infusion spiral CT for theevaluation of remnant stomach and anastomosis site in patients who have undergone subtotal gastrectomy for stomachcancer. MATERIAL AND METHODS: A new technique named Levin tube inserted drip infusion spiral CT was used toprospectively study 23 patients. A 16Fr Levin tube was inserted into the remnant stomach ; 500ml of tap water wasdrip infused just before CT scanning and an additional 500ml of water was infused during IV contrast injection.Water was infused by gravity, using a water bottle suspended at a height of 90cm(Group A). The 31 patients whounderwent conventional spiral CT scanning immediately after the divided ingestion of 900ml diluted gastrografinwere selected as a control group(Group B). The anatomic delineation of the anastomosis site was graded by tworadiologists as excellent(3), good(2), fair(1) or poor(0). To evaluate the degree of distension, the maximaldiameters of remnant stomach and the anastomosis site, and the thickness of the stomach wall, were also measured. RESULTS: In group A, anatomic delineation of the anastomosis site was excellent, compared to group B(mean score:2.91 vs 1.19, P<0.01). In addition, the maximum diameters of remnant stomach and anastomosis site weresignificantly larger in group A than in group B(transverse A-P remnant stomach and anastomosis site : 92.4+/-16.0mm, 97.6+/-26.5mm, 29.7+/-7.3mm vs 50.6+/-12.9mm, 53.5+/-14.4mm, 7.7+/-4.4mm, P<0.01). The mean thickness of distended stomach wallin group A was 3.2+/-1.7mm ; in group B, measurement was possible in only a few cases, but their number was too smallfor comparison. CONCLUSION: In patients who had undergone subtobal gastrectomy, Levin tube inserted drip infusionspiral CT showed excellent anatomic delineation of the site of anastomosis and remnant stomach. We found thatbecause it increases the distension of remnant stomach and the anastomosis site, this technique is effective forthe evaluation of postoperative stomach.

Atrophy of the Left Hepatic Lobe Caused by a Biliary Tract Disease

PURPOSE: To study the CT patterns of left lobar atrophy, including pathologic and hemodynamic features, incases of primary biliary disease. MATERIALS AND METHODS: CT findings of left hepatic lobar and segmental atrophyin 26 patients with histologically or radiologically-proven underlying bile-duct disease were reviewed. Seventeen cases were oriental cholangiohepatitis (OCH) with left intrahepatic stones and nine were cholangiocarcinomainvolving the hilar or left hepatic bile duct. The distribution and appearance of atrophy and adjacent lobarhypertrophy were studied. CT scans were examined for the presence of stenosis or obstruction of the left portalvein, and the enhancing pattern of lobar atrophy was analysed. In patients who had undergone left lobectomy, themechanism of lobar atrophy was correlated with radiographic and pathologic features. RESULTS: All patients showedbile duct dilatation localized to atrophic left hepatic segments. In cholangiocarcinoma, the distribution ofatrophy was characteristically lobar, in contrast to segmental distribution in OCH. Compensatory hypertrophy wasmore common in OCH and particularly involved the caudate lobe. Organic and functional occlusion of the left portalvein was a cause of atrophy, even in OCH. Periportal fibrosis and inflammation were the main pathological featureof atrophy. On spiral CT scan, delayed enhancement of atrophic liver parenchyma was the characteristic feature. CONCLUSION: Lobar or segmental left hepatic lobe atrophy is seen in bile duct disease caused by OCH orcholangiocarcinoma. This finding suggests that the disease process is advanced, and that there is obstruction ornarrowing of the left portal vein, associated with periportal fibrosis and inflammation.

Intrahepatic cholangiocarcinoma presenting as liver Abscess: Report of Two Cases

Intrahepatic cholangiocarcinoma is the second most common primary malignant hepatic neoplasm. We describe twocases of intrahepatic cholangiocarcinoma which initially presented as liver abscess both clinically andradiologically. Mucin-hypersecretion from the tumor cells and extensive necrosis or secondary bacterial infectionwas responsible for the radiologic appearance of a liver abscess.

Colo-colic Intussusception due to Large Colonic Lipoma: A Case Report

Colonic lipomas are the second most common benign tumor of the large bowel; because they are small, they are usually asymptomatic. If there is bleeding or obstruction, however, surgical management is mandatory. These tumors may have a broad-based pedicle, and their diameter is usually less than 3cm. We report a case of colo-colonic intussusception due to certain unique features of this colonic lipoma; a narrow pedicle, giant size, and severe necrosis.

Dupplex Doppler Sonography in Patients with Medical Renal Diseases: Correlation with Clinical and Histopathologic Findings

PURPOSE: To compare the RI (resistive index) of renal artery with serum creatinine level and histological change in 50 patients with renal parenchymal disease. MATERIALS AND METHODS: To measure RI in each patient, Doppler studies were performed three times in each kidney at the level of the interlobar arteries, and the average value of RI was taken. The study was performed 1-3 days after renal biopsy and the time interval between blood sampling for serum creatinine and duplex study was also 1-3 days. The RI of patients with renal disease was also correlated with patient's age, sex and serum creatinine level, and RI was also correlated with the degree of severity of glomerular, interstitial, and vascular change in the kidneys. Statistical analysis was performed using Student's t test and Pearson's correlation method. RESULTS: The RI of the normal control and renal disease group was 0.566+/-0.037 and 0.584+/-0.038, respectively with no statistical significance (p=0.444). In the group with renal disease, there was no significant correlation between RI and a patient's age, sex, and serum creatininelevel (p>0.05). RI was not significantly different between predominantly glomerular disease (n=45) and nonglomerular or mixed disease (n=5) (p=0.558), and did not correlate with the severity of glomerular sclerosis, interstitial fibrosis, or atherosclerosis (p>0.05). CONCLUSION: The authors conclude that RI is not helpful for the diagnosis and differential diagnosis of renal parenchymal diseases and does not correlate with serum creatinine levels. In order to define the role of the RI, further clinical experience with more cases is required.

Normal Anatomical Variation of the Intrahepatic Portal Vein in Korean

PURPOSE: To determine the prevalence of variations in the intrahepatic portions of portal veins, as visualized by arterial portograms, and to examine the surgical implications of these findings in Koreans. MATERIALS AND METHODS: Five hundred and nineteen arterial portograms of 519 patients with no evidence of vascular tumor invasion or distortion were retrospectively reviewed. In all patients, the main, right, right anterior, right posterior and left portal vein were visualized. RESULTS: Variations in intrahepatic portal anatomy were found in 102 patients (19.6%) and involved an immediate trifurcation of the main portal vein in 82 (15.8%) a right posterior segment from the main portal vein in ten (1.9%), a right anterior segment from the left portal vein in nine (1.7%) and an absent horizontal portion from the left portal vein in one (0.2%). CONCLUSION: On arterial portogram, variations in the intrahepatic portions of the portal veins are frequently seen. The recognition of such variations is important in the preoperative evaluation of patients with hepatic tumors, since the variations may have implications for tumor resection, for the localization of tumor thrombi and in interventional radiologic procedures involving the portal vein.

Sclerosing Hepatocellular Carcinoma: Case Report

Sclerosing hepatocellular carcinoma is a rare primary hepatocellular neoplasm which is not associated with hepatitis type B and liver cirrhosis. It is characterized by intense fibrosis in which the tubular neoplastic structures are embedded. The authors report a case of sclerosing hepatocellular carcinoma which mimics hemangioma or hypervascular metastatic tumor and on sprial CT shows early enhancement of the cellular component and delayed enhancement of the fibrotic component.

Hepatoid Adenocarcinoma of the Stomach: Radiologic Findings

PURPOSE: Hepatoid adenocarcinoma of the stomach is a variant of gastric carcinoma with both adenocarcinoma and hepatocellular carcinomatous differentiations. Until recently, few reports had been published. The purpose of this study was to evaluate the radiologic characteristics of eleven hepatoid adenocarcinomas of the stomach aswell as patterns of metastasis. MATERIALS AND METHODS: Eleven pathologically proven cases of hepatoidadeno carcinoma of the stomach were retrospectively reviewed. Radiologic studies available were CT in eight patients, abdominal ultrasonography in ten, upper GI series in seven, and hepatic angiography in two. Pathologicand radiologic characteristics of these lesions, patterns of metastasis, if present, and labolatory data(AFP andCEA) were evaluated. RESULTS: Tumors were seen in the antrum and body in five patients, in the antrum in five, and in the body of the stomach in one. Six tumors were classified as Borrmann type 3, four as Borrmann type 2, andone as Borrmann type 4. Nine cases showed hepatic metastasis. Portal vein thrombosis was present in three cases ;two were accompanied by multiple liver metastasis and the other had portal venous thrombosis. Lymph nodemetastasis was identified in 11 cases ; N1 in five, N2 in five, and extensive retroperitoneal paraaortic and left supraclavicular lymphadenopathy in one. Angiography showed hypervascular metastatic liver masses in two cases.There was no evidence of metastasis to the mesentery, omentum, and peritoneum. Serum AFP was elevated in tencases(mean : 24752.2 ; median : 4230 ng/ml). CONCLUSION: Radiologic findings of hepatoid adenocarcinoma of thestomach appear similar to those of non-hepatoid adenocarcinoma. However, elevation of AFP and early liver metastasis without peritoneal metastasis is suggestive of hepatoid adenocarcinoma of the stomach.

A Case of the Multiple Intussusceptions of Small Bowel by Metastatic Malignant Melanoma / 대한소화기내시경학회지

We present herein the case of 31-year-old man with disseminated malignant melanoma in whom a multiple metastasis into jejunum causing multiple intussusceptian. At laparotomy, multiple variable sized metastatic melanoma were noted on proximal and distal jejunum. To our knowledge, there was no report about multiple intussusceptions by malignant melanoma in Korea.

A Case of the Multiple Intussusceptions of Small Bowel by Metastatic Malignant Melanoma / 대한소화기내시경학회지

We present herein the case of 31-year-old man with disseminated malignant melanoma in whom a multiple metastasis into jejunum causing multiple intussusceptian. At laparotomy, multiple variable sized metastatic melanoma were noted on proximal and distal jejunum. To our knowledge, there was no report about multiple intussusceptions by malignant melanoma in Korea.