No-Touch Radiofrequency Ablation for Early Hepatocellular Carcinoma: 2023 Korean Society of Image-Guided Tumor Ablation Guidelines

Radiofrequency ablation (RFA) has been widely used to manage hepatocellular carcinomas (HCCs) equal to or smaller than 3 cm. No-touch RFA has gained attention and has recently been implemented in local ablation therapy for HCCs, despite its technical complexity, as it provides improved local tumor control compared to conventional tumor-puncturing RFA. This article presents the practice guidelines for performing no-touch RFA for HCCs, which have been endorsed by the Korean Society of Image-Guided Tumor Ablation (KSITA). The guidelines are primarily designed to assist interventional oncologists and address the limitations of conventional tumor-puncturing RFA with describing the fundamental principles, various energy delivery methods, and clinical outcomes of no-touch RFA. The clinical outcomes include technical feasibility, local tumor progression rates, survival outcomes, and potential complications.

Complete response to local therapy for advanced hepatocellular carcinoma with lung metastasis: a case report

The concept of oligometastasis is widely accepted for various types of solid tumors; accordingly, better outcomes can be anticipated with aggressive local interventions. The treatment of advanced hepatocellular carcinoma (HCC) with extrahepatic metastasis is systemic therapy. However, treatment responses to systemic therapy are poor. Recently, a small number of metastatic cancers (oligometastasis) have been controlled by local therapy rather than systemic therapy. Our study reports a case of a 66-year-old male patient with advanced HCC with lung metastasis, which was treated with local therapy. There were less than four metastases in the lungs, which were treated with wedge resection, radiofrequency, and radiation therapy. He repeatedly underwent local therapy for lung oligometastasis and locoregional therapy for intrahepatic HCC rather than systemic therapy; control by local therapy was possible as his liver function was preserved with Child-Turcotte-Pugh class A.

Combination Therapy of Angiotherapy, Radiation Therapy, and Radiofrequency Ablation for Pulmonary Metastasis of Hepatocellular Carcinoma Accompanied by Nontuberculous Mycobacteria

With the advances in hepatocellular carcinoma (HCC) treatment, the lung metastasis of HCC is becoming increasingly important. In treating the lung metastasis of HCC, a multidisciplinary approach can lead to better results than systemic chemotherapy alone. Here, we report on a patient who presented with pulmonary masses, while the HCC was being controlled in the abdominal cavity. The presence of nontuberculous mycobacteria was identified during the diagnosis of the pulmonary masses. The pulmonary metastases of HCC were treated with a combination of angiotherapy, radiation therapy, and radiofrequency ablation. The patient showed a satisfactory progress with this multidisciplinary localized treatment. We report the clinical progress and review the recent literature regarding the treatment of pulmonary metastasis without intrahepatic HCC herein.

Long-Term Efficacy and Safety of Partial Splenic Embolization in Hepatocellular Carcinoma Patients with Thrombocytopenia Who Underwent Transarterial Chemoembolization

BACKGROUND: Performing transarterial chemoembolization (TACE) is difficult with the occurrence of thrombocytopenia in cirrhotic patients with hepatocellular carcinoma (HCC). We aimed to evaluate the long-term efficacy and safety of partial splenic embolization (PSE) combined with TACE in patients with HCC with severe thrombocytopenia related to splenomegaly. METHODS: We conducted a case–control study consisting of 18 HCC patients with severe thrombocytopenia (< 50 × 109/L) who underwent PSE concurrently with TACE (PSE group) and 72 controls who underwent TACE alone (non-PSE group). RESULTS: Mean platelet counts at 1 month and 1, 3, and 5 years after concurrent PSE and TACE significantly increased compared with baseline (all P < 0.05), whereas the platelet count did not significantly increase after TACE alone. In addition, the platelet count at several time points after treatment in the PSE group was significantly higher than that in the non-PSE group, although the baseline platelet count in the PSE group was significantly lower than that in the non-PSE group. The platelet increase after PSE significantly reduced the need for platelet transfusions (P = 0.040) and enabled the subsequent TACE procedures in time (P = 0.046). The leukocyte counts and hemoglobin concentrations after concurrent PSE and TACE were also significantly increased, without deterioration of Child-Turcotte-Pugh score and unexpected side effects. CONCLUSION: PSE combined with TACE is effective in inducing and maintaining long-term thrombocytopenia improvement which reduces the need for the platelet transfusion and helps to perform initial and serial TACE, and is well-tolerated in patients with HCC and thrombocytopenia. PSE may be a promising treatment option for HCC patients with severe thrombocytopenia associated with splenomegaly who will undergo TACE.

Percutaneous placement of self-expandable metallic stents in patients with obstructive jaundice due to hepatocellular carcinoma

“Icteric type hepatoma” is a hepatocellular carcinoma (HCC) with tumor invasion to the bile duct (bile duct tumor thrombus, BDTT) causing obstructive jaundice. Effective and long-term decompression of the bile duct is essential for the palliative treatment for the patients. Percutaneous self-expandable metallic stent placement is a well-established treatment for palliating patients with an inoperative malignant biliary obstruction. This article reviews the treatment of percutaneous placement of self-expandable metallic stents for the management of obstructive jaundice caused by HCC.

Complete cure of advanced hepatocellular carcinoma with right adrenal gland metastasis and portal vein thrombosis by multiple applications of an interdisciplinary therapy: Case report with 8-year follow up

Hepatocellular carcinoma (HCC) is the sixth most common cause of death worldwide and the main cause of primary liver cancer. The principle problem of HCC is the poor prognosis, since advanced HCC reportedly has a median survival of only 9 months. The standard therapies are sorafenib and regorafenib, but the outcomes remain unclear. We report a 60-year-old man with advanced HCC with right adrenal gland metastasis and portal vein tumor thrombosis, who showed a complete response to multiple applications of an interdisciplinary therapy.

Correlation between Overactive Bladder Syndrome and Obsessive Compulsive Disorder in Women / 가정의학회지

BACKGROUND: Overactive bladder syndrome is characterized by urinary urgency, usually accompanied by Frequent urination and nocturia, with or without urgent urinary incontinence. There must be the absence of causative infection or pathological conditions. Overactive bladder syndrome is related to mental disorders, particularly depression and anxiety. However, obsessive-compulsive symptoms are investigated much less frequently. The purpose of the present study was thus to assess obsessive-compulsive symptoms in overactive bladder syndrome patients. METHODS: Fifty-seven women patients with overactive bladder syndrome and fifty-seven women without it (age matched control group) were prospectively enrolled. They completed the overactive bladder syndrome-validated 8-question screener and the Korean version of the Maudsley Obsessional-Compulsive Inventory Questionnaire at the same time they visited the clinic. Patients were compared with controls on the Korean version of the Maudsley Obsessional-Compulsive Inventory Questionnaire and its checking, tidiness, doubting, and fear of contamination components. RESULTS: Patients showed more obsessive traits than controls on the Korean version of the Maudsley Obsessional-Compulsive Inventory Questionnaire total score (P=0.006) and on the checking subscale (P=0.001). Odds ratio for the overactive bladder syndrome group's obsessive-compulsive symptoms traits (score> or =14) was 5.47 (P=0.001). The Korean version of the Maudsley Obsessional-Compulsive Inventory Questionnaire total score was associated with the overactive bladder syndrome-validated 8-question screener score in patients (P=0.03). CONCLUSION: Obsessive-compulsive symptoms may constitute an important aspect of the psychiatric profile of overactive bladder syndrome patients. The severity of obsessive-compulsive symptoms seems to be related to the degree of the overactive bladder syndrome severity. Clinicians may consider screening women with overactive bladder syndrome for obsessive-compulsive symptoms.

The Risk for Insulin Resistance according to the Degree of Non-Alcoholic Fatty Liver Disease in Korean Men

Insulin resistance (IR) plays a significant role in the development and progression of non-alcoholic fatty liver disease (NAFLD). However, the natural course of insulin sensitivity under NAFLD remained unclear. Accordingly, this study was designed to investigate the effect of NAFLD on insulin resistance. A total of 20,628 Korean men without homeostasis model assessment of insulin resistance (HOMA-IR < 2.7) were followed-up for 5 years. They were serially checked for HOMA-IR to monitor the development of IR (HOMA-IR ≥ 2.7). The incidence rate of IR increased according to the degree of NAFLD (normal: 11.6%, mild: 28.8%, moderate to severe: 40.5%, P < 0.001). Cox proportional hazards model showed that HRs (95% CI) for IR increased proportionally to the degree of NAFLD (mild: 1.19 [1.02–1.39], moderate to severe: 1.32 [1.08–1.57]). IR was more potentially associated with the more progressive NAFLD than normal and milder state. In addition, NAFLD was the independent risk factor of the development of IR. These results suggest the potential availability of NAFLD as a predictor of IR.

A Case of Vidian Nerve Schwannoma: Resection by Endoscopic Sinus Surgery / 대한이비인후과학회지

Schwannoma is a benign tumor arising from the sheath of myelinated nerve fibers and may occur in any part of the body. However, a vidian nerve schwannoma is extremely rare. A 41 year-old man has experienced an occipital area headache and posterior neck stiffness for 2 weeks. Brain computed tomography (CT) angiography, magnetic resonance image revealed lobulated soft tissue density mass in left sphenoid sinus with upward displacement of sphenoid sinus floor and pressure erosion of sphenoid sinus and petrous apex. Ostiomeatal unit CT scan showed a 28x16 mm sized mass filling the left pterygoid canal. The mass was resected using endoscopic sinus surgery. The mass was confirmed as schwannoma. We report a case of vidian nerve schwan-noma that was treated by endoscopic sinus surgery.

Aggravation of Relapsing Polychondritis due to the Infection and Its Manifestation on a Nasal Tip Graft

Relapsing polychondritis (RP) is an uncommon systemic disease that is characterized by episodic and progressive inflammation of the cartilaginous structures, which can be very debilitating and in some instances life-threatening. The pathogenic pathways of RP are largely unknown. However, several hypothesis have been suggested. We had an interesting case of aggravation of RP due to the infection. Graft cartilage on the nasal tip was affected by RP also. This case can give a clue of revealing the pathogenesis of RP. We introduce a case with a review of the literature.

Percutaneous Placement of Self-Expandable Metallic Stents in Patients with Obstructive Jaundice Secondary to Metastatic Gastric Cancer after Gastrectomy

OBJECTIVE: To evaluate the outcomes of patients undergoing percutaneous placements of a biliary stent for obstructive jaundice secondary to metastatic gastric cancer after gastrectomy. MATERIALS AND METHODS: Fifty patients (mean age, 62.4 years; range, 27-86 years) who underwent percutaneous placements of a biliary stent for obstructive jaundice secondary to metastatic gastric cancer after gastrectomy were included. The technical success rate, clinical success rate, complication rate, stent patency, patient survival and factors associated with stent patency were being evaluated. RESULTS: The median interval between the gastrectomy and stent placement was 23.1 months (range, 3.9-94.6 months). The 50 patients received a total of 65 stents without any major procedure-related complications. Technical success was achieved in all patients. The mean total serum bilirubin level, which had been 7.19 mg/dL +/- 6.8 before stent insertion, decreased to 4.58 mg/dL +/- 5.4 during the first week of follow-up (p < 0.001). Clinical success was achieved in 42 patients (84%). Percutaneous transhepatic biliary drainage catheters were removed from 45 patients (90%). Infectious complications were noted in two patients (4%), and stent malfunction occurred in seven patients (14%). The median stent patency was 233 +/- 99 days, and the median patient survival was 179 +/- 83 days. Total serum bilirubin level after stenting was an independent factor for stent patency (p = 0.009). CONCLUSION: Percutaneous transhepatic placement of a biliary stent for obstructive jaundice secondary to metastatic gastric cancer after gastrectomy is a technically feasible and clinically effective palliative procedure.

A Case of Jugular Bulb Diverticulum Invading the Internal Auditory Canal

Jugular bulb diverticulum (JBD) is a rarely reported vascular anomaly, which is an extraluminal outpouching from the jugular bulb. Especially, there exists a lack of reported cases involving JBD encroaching the internal auditory canal (IAC) in Korea. Subjects with JBD may be asymptomatic or have variable symptoms based on its location and size. In this article, we report a unique case of JBD eroding into the IAC that was presented as sudden sensorineural hearing loss with vertigo.

Clinical Analysis of Characteristics of Patients Who Visit Otorhinolaryngology Clinic in Secondary General Hospital / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Common cold is an upper airway viral infection and can be managed by conservative treatment. According to the hospital referral system, mild diseases like common cold should be treated first at a primary physician clinic. However, now in Korea, visiting high-level hospitals for mild diseases is not impossible officially and even the rate of visiting high-level general hospital has increased in spite of the current hospital referral system. This study aimed to provide data of characteristics of patients who choose high-level hospitals for mild diseases like common cold. SUBJECTS AND METHOD: We conducted a survey targeting those who visit general hospitals for common cold. The questionnaire comprised of asking first choice of contact hospital, sex, age, awareness and use of antibiotics when visiting primary physician, medical examinations and duration of treatment, and reasons for thinking that general hospitals are superior to primary hospitals. Subjects were categorized according to their choice of first contact hospital with common cold, primary physician or general hospital. For each group, independent sample t-test and chi-square test were applied to variables. RESULTS: Among the variables for the two groups, statistical significances were found in age, duration of treatment and whether medical examinations were performed or not. CONCLUSION: Underestimation for primary physician and vague faith in medical examinations were most influential factors that lead patients with mild diseases to visit general hospitals. This study finds that programs for educating the public are necessary to make them understand that primary physician clinics are enough to treat common cold and that an institutional framework will be needed to support the hospital referral system.

Massive Paradoxical Air Embolism in Brain Occurring after Central Venous Catheterization: A Case Report

Cerebral air embolism is a rare but fatal complication of central venous catheterization. Here, we report a case of paradoxical cerebral air embolism associated with central venous catheterization. An 85-yr-old man underwent right internal jugular vein catheterization, and became obtunded. Brain MR imaging and CT revealed acute infarction with multiple air bubbles on the side of catheter insertion. The possibility of cerebral air embolism should be considered in patients developing neurological impairment after central venous catheterization, and efforts should be made to limit cerebral damage.

A Case of Hepatic Cyst Infection Diagnosed by 18F-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography in Autosomal Dominant Polycystic Kidney Disease / 대한신장학회지

Infection of hepatic cyst is a serious complication of autosomal dominant polycystic kidney disease (ADPKD). Early diagnosis of infected cyst is crucial and usually requires conventional modalities, including ultrasound and computed tomography. However, their contribution is limited because of nonspecific results. We report a case of hepatic cyst infection for which 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) scan allowed the exact localization of the infected cyst and the precise drainage procedure. A 48-year-old woman with ADPKD presented with fever and RUQ pain. Contrast enhanced computed tomography did not show any evidence of complicated or infected cysts in both kidneys and liver. Though she had been treated by antibiotics for 7 days, patient's symptoms were not improved. However, 18F-FDG PET-CT scan revealed infected cyst in the left lobe of liver exactly. After percutaneous drainage based on 18F-FDG PET-CT imaging, the hepatic cyst infection was controlled. Therefore, 18F-FDG PET-CT imaging could be a valuable tool to identify the exact localization of cyst infection, which may contribute to drain the infected cyst. We report this case with a brief review of relevant literature.

The relationship between the ApoB/ApoA-I ratio and non-alcoholic fatty liver disease in prediabetic patients / 대한내과학회지

BACKGROUND/AIMS: The apolipoprotein B/A-I ratio (ApoB/A-I) is a powerful clinical indicator of atherosclerosis. Although numerous reports have shown the effect of non-alcoholic fatty liver disease (NAFLD) on cardiovascular disease, few reports have examined the relationship between NAFLD and the ApoB/A-I ratio. The aim of the study was to determine the association between NAFLD and the ApoB/A-I ratio in prediabetic patients. METHODS: This cross-sectional study was performed with data obtained from 701 patients (mean age, 47.9+/-9.6 years) diagnosed with prediabetes. Serum lipid profiles including lipoprotein, apolipoprotein, and calculated ApoB/A-I ratio as well as metabolic syndrome parameters such as fasting glucose and insulin were measured in each subject. RESULTS: Among the 701 patients, 340 (48%) had NAFLD. The number of male patients was 490 (NAFLD+, 276; and NAFLD-, 214). The odds ratios for the prevalence of NAFLD increased according to the quartiles of the ApoB/A-I ratio (1.886, 2.245, and 2.587) (p<0.001). CONCLUSIONS: The prevalence of NAFLD correlated with high ApoB/A-I ratio, suggesting that NAFLD increases the risk for atherosclerosis progression in male prediabetic patients.

Preoperative Diagnosis of Extraglandular Invasion of Thyroid Papillary Carcinoma: High Resolution Sonography versus Multidetector Computed Tomography

PURPOSE: To compare the diagnostic efficacy of high-resolution sonography (HRS) and multidetector computed tomography (MDCT) in determining the presence of extraglandular invasion of thyroid papillary cancer and to define ultrasound (US) features of perithyroidal invasion that correlate with histopathological findings. MATERIALS AND METHODS: We prospectively evaluated extracapsular invasion in 177 thyroid cancer patients using both HRS and MDCT. Receiver operating characteristics (ROC) were assessed with a four-point confidence scale (0 = no extracapsular invasion; 1 = possible invasion; 2 = probable invasion; 3 = definite invasion) by two reviewers for each imaging modality. Sensitivity, specificity, and accuracy were analyzed for each modality, along with interobserver variability. RESULTS: MDCT had a mean area under the ROC curve larger than that of HRS (HRS = 0.733, MDCT = 0.807, p < 0.05). HRS and MDCT were significantly different with regard to diagnostic sensitivity, specificity, and accuracy for extrathyroidal extension (p < 0.05; HRS = 75.7%, 66.1%, and 69.8%, respectively; MDCT = 86.7%, 69.7%, and 76%, respectively). Interobserver reliability was greater for MDCT than for HRS (kappa value, 0.861 versus 0.429). The cutoff value used in HRS for estimating the status of perithyroidal invasion was 2. CONCLUSION: HRS may be useful for preoperative investigation of thyroid papillary carcinoma extension, but it was inferior to MDCT because of lower diagnostic accuracy and lower interobserver reliability.

Extracolonic Findings of CT Colonography: Frequency Analysis between Symptomatic and Asymptomatic Patients

PURPOSE: To perform a frequency analysis of the extracolonic findings (ECF) of the CT colonography between symptomatic and asymptomatic patients. MATERIALS AND METHODS: Seventy-two consecutive symptomatic patients and sixty-three consecutive asymptomatic patients who underwent CT colonography were enrolled in this study. Non-contrast enhanced axial images were reviewed retrospectively to identify the ECF and classified them as major, moderate or minor important findings according to their potential clinical importance. The frequencies of each classification and ECF were analyzed and compared between two groups (symptomatic and asymptomatic). RESULTS: Eighty-two ECF were identified in 49 (68.1%) of the 72 symptomatic patients. The findings were classified as follows: major (8/49, 11.1%), moderate (17/49, 23.6%), minor (39/49, 54.2%). Sixty ECF were detected in 38 (60.3%) of the 63 asymptomatic patients. The findings were classified as follows: major (2/38, 3.2%), moderate (7/38, 11.1%), minor finding (35/63, 55.6%). No statistically significant differences were found between the two groups (p > 0.05) for the overall ECF frequency. However, a significantly higher frequency of major or moderate ECF was observed in symptomatic patients (30.6%) compared to asymptomatic patients (12.7%) (p < 0.05). CONCLUSION: The overall ECF frequency was similar between symptomatic and asymptomatic patients; however, the frequency of clinically important ECF (major or moderate) was higher in symptomatic patients, compared to asymptomatic patients. This result suggests that the major or moderate ECF required a further work up or treatment in symptomatic patients.

Clinical Outcomes after Peripheral Balloon Angioplasty or Stent Insertion in Patients with Peripheral Arterial Obstructive or Stenotic Disease

PURPOSE: Percutaneous peripheral balloon angioplasty and stent insertion are used for the treatment of peripheral arterial obstructions and stenosis. In this study, we assessed the efficacy of peripheral balloon angioplasty and stent insertion in patients with peripheral arterial disease. METHOD: We performed a retrospective review of patients who underwent peripheral balloon angioplasty or stent insertion in obstructive or stenotic peripheral arterial lesions between July 2003 and November 2006. Follow-up study was performed using lower extremity multi-directional computed tomography (MDCT) or lower extremity angiography. Mean follow-up was 22.8 months. RESULT: A total of 30 patients (47 lesions) were treated. The mean age was 66.8 years, and the ratio of male to female patients was 29 to 1. Calf claudication was the most common chief complaint, and 19 patients had hypertension. Obstructive lesions were found in the common iliac artery (CIA) (18), external iliac artery (EIA) (11), superficial femoral artery (SFA) (15), and anterior tibial artery (ATA) (3). Peripheral balloon angioplasty was performed for 8 lesions, and stent insertion was performed for 39 lesions. Re-stenosis occurred in 9 lesions (3 in the CIA, 5 in the SFA, 1 in the ATA) during follow-up. CONCLUSION: Peripheral balloon angioplasty and stent insertion are useful modalities for the treatment of obstruction or stenosis in lower extremity peripheral arteries. Close follow-up is necessary to improve long-term outcomes.

Ultrasonographic Findings of an Implanted Absorbable Mesh in Patients with Breast Partial Resection: a Preliminary Study

PURPOSE: To present the ultrasonographic findings of an implanted absorbable mesh in patients who underwent breast partial resection. MATERIALS AND METHODS: We retrospectively analyzed the ultrasonographic findings of 18 patients who underwent breast partial resection with an absorbable mesh implant to minimize the breast deformity. Sonography was performed approximately 3 months after surgery (mean interval, 92 days). The presence of a capsule and cyst at the surgical site, the size of the cyst, internal content of the cyst, vascularity of the lesion, and presence of complications were analyzed. RESULTS: An ultrasound examination revealed a well-encapsulated cyst with regular capsule in 16 of the 18 patients. The longest diameter of the cyst varied from 3 cm to 10 cm. Among 16 cases that showed a well-encapsulated cyst, 11 cases showed an isoechoic nodular pattern in the cyst and in the remaining five cases, the internal nodular pattern was not seen. In two of the18 cases, an isoechoic nodular pattern without fluid content was seen for the lesions. A Doppler study revealed no vascularity in any of the lesions. CONCLUSION: Ultrasonographic findings of an implanted absorbable mesh, inserted in the surgical site to minimize breast deformity in patients that underwent breast partial resection, showed the presence of a well-encapsulated cyst with an internal isoechoic nodular pattern in the majority of the cases.