The effects of surgical treatment and sclerotherapy for intramuscular venous malformations: a comparative clinical study

Background@#Venous malformations (VMs) are the most common type of vascular malformations. Intramuscular venous malformations (IMVMs) are lesions involving the muscles, excluding intramuscular hemangiomas. The purpose of this study was to compare clinical outcomes between patients with IMVMs who were treated with sclerotherapy and those who were treated with surgical excision. @*Methods@#Of 492 patients with VMs treated between July 2011 and August 2020 at a single medical center for vascular anomalies, 63 patients diagnosed with IMVM were retrospectively reviewed. Pain, movement limitations, swelling, and quality of life (QOL) were evaluated subjectively, while radiological outcomes were assessed by qualified radiologists at the center. Complication rates were also evaluated, and radiological and clinical examinations were used to determine which treatment group (sclerotherapy or surgical excision) exhibited greater improvement. @*Results@#Although there were no significant differences in pain (P=0.471), swelling (P=0.322), or the occurrence of complications (P=0.206) between the two treatment groups, the surgical treatment group exhibited significantly better outcomes with regard to movement limitations (P=0.010), QOL (P=0.013), and radiological outcomes (P=0.017). Moreover, both duplex ultrasonography and magnetic resonance imaging showed greater improvements in clinical outcomes in the surgical excision group than in the sclerotherapy group. @*Conclusions@#Although several studies have examined IMVM treatment methods, no clear guidelines for treatment selection have been developed. Based on the results of this study, surgical excision is strongly encouraged for the treatment of IMVMs.

Comparison of Coronary Plaque and Stenosis Between Coronary Computed Tomography Angiography and Virtual Histology-Intravascular Ultrasound in Asymptomatic Patients with Risk Factors for Coronary Artery Disease

OBJECTIVES: The purpose of the study was to compare plaque characteristics by coronary computed tomography angiography (CCTA) with those by virtual histology-intravascular ultrasound (VH-IVUS). METHODS: We enrolled 50 asymptomatic patients with diabetes mellitus or more than two risk factors for coronary artery disease such as hypertension, smoking, and hyperlipidemia. If the patient had a coronary lesion (plaque with more than 50% stenosis or calcium score more than 100), we recommended coronary angiography and VH-IVUS and compared CCTA findings with VH-IVUS findings. RESULTS: 35 patients (70%) had coronary lesions, and we performed both CCTA and VH-IVUS in 23 patients. All 23 patients had multiple risk factors, and the majority of target lesions were located at left anterior descending artery (73.9%), and calcium score of lesion site was 106+/-162 with plaque volume of 232+/-153 mm3 by CCTA. Calcium score of lesion site was significantly greater in diabetic patients (n=14) than non-diabetic patients (n=9) (118+/-159 vs. 88+/-175, p=0.038). By VH-IVUS, plaque volume was 174+/-127 mm3, absolute necrotic core (NC) volume was 22+/-21 mm3, and relative NC volume was 20.8+/-8.7%. Absolute dense calcium (DC) volume and absolute NC volumes were significantly greater in diabetic patients than non-diabetic patients (11.5+/-13.8 mm3 vs. 9.1+/-11.0 mm3, p=0.028, and 23.9+/-24.7 mm3 vs. 18.1+/-14.3 mm3, p=0.035, respectively). Plaque volume by CCTA correlated with that of VH-IVUS (r=0.742, p<0.001), and plaque volume by CCTA correlated with absolute NC volume by VH-IVUS (r=0.621, p<0.001), and calcium score of lesion site by CCTA correlated with absolute dense calcium volume by VH-IVUS (r=0.478, p=0.028). CONCLUSION: Coronary lesion was detected by CCTA in 70% of asymptomatic patients with multiple coronary risk factors, and parameters detected by CCTA correlated well with those detected by VH-IVUS.

Improved Specificity of 18F-FDG PET/CT for Lymph Node Staging of Non-Small Cell Lung Cancer Considering Calcified Lymph Node as Benign / 핵의학분자영상

PURPOSE: We evaluated the diagnostic value of 18F-FDG PET/CT (PET/CT) in lymph node staging of non-small cell lung cancer (NSCLC) considering calcification and histologic types as well as FDG uptake. MATERIALS AND METHODS: Fifty-three patients (38 men, 15 women; mean age, 62 years) with NSCLC underwent surgical resection (tumor resection and lymph node dissection) after PET/CT. After surgery, we compared PET/CT results with the biopsy results, and analyzed lymph node metastases, based on histologic types. PET diagnosis of lymph node metastasis was determined by maximum SUV (maxSUV) > 3.0, and PET/CT diagnosis was determined by maxSUV > 3.0 without lymph node calcification. RESULTS: By PET diagnosis, the sensitivity, specificity, and accuracy of overall lymph node staging were 45% (13 of 29), 91% (228 of 252), and 86% (241 of 281). Specificity was 91% in both squamous cell carcinoma and adenocarcinoma, while sensitivity was 71% in squamous cell carcinoma and 36% in adenocarcinoma. When we excluded calcified lymph node with maxSUV > 3.0 from metastasis by PET/CT diagnosis, specificity improved to 98% in squamous cell carcinoma and 97% in adenocarcinoma. The degree of improvement was not dependent on histologic types. CONCLUSION: PET/CT improved specificity of lymph node staging by reducing false positive lymph node regardless of histologic types of NSCLC.

Two Cases of Fractured and Embolized Implanted Central Venous Chemoports in Lung Cancer / 결핵및호흡기질환

Totally implanted central venous access devices for chemotherapy (chemoport) are being used increasingly in lung cancer patients. Vascular catheters are associated with various complications including infection, thrombosis as well as spontaneous fractures and embolization of the catheter, which is known as 'pinch-off syndrome'. 'Pinch-off syndrome' refers to the compression of a subclavian central venous catheter between the clavicle and first rib resulting in an intermittent or permanent obstruction, which can lead to tears, transection, or embolization. We report two cases of fractured and embolized implanted subclavian venous catheters in which the fragments were removed percutaneously. A 62-year-old man presented with back pain with a duration of a few weeks. The chest radiograph revealed complete transsection and embolization of the catheter into the right atrium. In addition, a 47-year-old woman with a chemoport had a grade 3 pinch-off sign in a chest radiograph demonstrating complete transsection and embolization of the catheter into the pulmonary artery. Both cases were managed by retrieving the embolized distal fragment percutaneously and removing the proximal section of the catheter.

Assessment of Neoplastic Angiogenesis Using Perfusion-Weighted MR Imaging: Experimental Study in VX2 Carcinoma in Rabbits

PURPOSE: To evaluate the perfusion-weighted MR imaging findings of hepatic VX2 carcinoma in rabbits and to explain the perfusion characteristics of this condition by correlation with the histopathological findings. MATERIALS AND METHODS: Twelve New Zealand white rabbits, each weighing between 2.5 and 3.5 (mean) 3.1kg, were used in this study. Perfusion MRI using single-shot gradient-echo EPI was performed 7 -21 days after the injection of tumor cell suspension into the hepatic parenchyma by laparotomy. On the basis of the calculated enhancement ratio, the time-intensity perfusion curves for VX2 tumor and normal liver parenchyma were created, and the shapes of these curves, the time to maximum SI decrease, and the maximum enhancement ratio in each, were evaluated. To assess microvessel density in each VX2 carcinoma and in normal liver parenchyma, immunohistochenical study using factor VIII-related antigen was performed. RESULTS: A total of 15 tumors 1 -3 cm in diameter were revealed by MR imaging. The perfusion curve showed rapid decrement and immediate recovery of the signal intensity of VX2 carcinoma during the early arterial perfusion phase and slower decrement and gradual recovery of that of normal liver parenchyma during the late portal perfusion phase. In all cases, these were constant findings. The time to maximum signal intensity decrease was 13 -16 (mean, 15) secs in VX2 carcinoma and 28 -36 (mean, 32) secs in normal liver parenchyma (p<0.01). The maximum enhancement ratio of VX2 carcinoma and normal liver ranged from 27 to 84% (mean 47%) and from 36 to 82% (mean, 56%), respectively. Immunohistochemical study showed that the MVD of VX2 carcinoma was significantly greater than that of normal liver parenchyma(75 vs 17, p<0.01). CONCLUSION: Perfusion-weighted MR imaging appears to be a useful tool for the diagnosis of neoplastic angio-genesis, and thus holds promise differentiating liver tumors.

A Case of Primary Pulmonary Hypertension with the Congenital Absence of Inferior Vena Cava

Primary pulmonary hypertension (PPH) is one of rare and fatal vascular disorder. The exact mechanisms for the increased pulmonary vascular resistance and pressure in PPH are unknown. The disease is advanced pro-gressively and patients naturally die within three years after the initial diagnosis. PPH is characterized with mean pulmonary artery pressure over 25-30 mmHg and intractable hypertension despite any intensive therapeutic maneuvers. Associated congenital anomaly is very rare. We report a 19 year-old female patient who diagnosed as PPH 10 years ago and suffered from severe pulmonary hypertension (100 mmHg of pulmonary arterial pressure) with the congenital absence of inferior vena cava. Her venous blood from lower body was drained through azygous vein into superior vena cava.

Diffusion-Weighted MR Imaging of the Brain Tumors: The Clinical Usefulness

PURPOSE: To evaluate the clinical usefulness of diffusion weighted MR imaging(DWI) in the differential diagnosis of brain tumors. MATERIALS AND METHODS: DWI and conventional MR images of nineteen patients with brain tumors(10 metastatic tumors, 4 high grade gliomas , 4 low grade astrocytomas, one oligodendroglioma)were obtained on 1.5T unit. DWI was obtained using single shot spin echo planar imaging with b-value near 1000. We analyzed the signal intensities of lesions including solid portion, necrotic or cystic portion and peritumoral edema of brain tumors (classified five grades comparison with the signal intensities of brain parenchyma and CSF)and calculate the SIR(signal intensity ratio)of lesions to the contralateral normal brain parenchyma. We analyzed statistically the signal intensities and SIR of tumors using independence T test. RESULTS: In solid portions of tumors, all the metastatic tumors and high grade gliomas showed high signal intensities, but low grade astrocytomas and oligodendroglioma showed iso or slight high signal intensities to the normal brain parenchyma. The SIR of solid portion has positive correlation with malignant potential(metastatic tumors 1.52, high grade gliomas 1.38, low grade astrocytomas 1.16, oligodendroglioma 1.31)(p<0.05). In peritumoral edema where seen in 14 tumors, seven of 10 metastatic tumors and two of 4 high grade gliomas showed iso signal intensities, whereas edemas in other 5 brain tumors showed hyperintense to the normal brain parenchyma. The SIRs of peritumoral edemas in metastatic tumors(1.14) was lower than high grade gliomas(1.31),but statistically insignificant. The SIR of cystic or necrotic portion of brain tumors was 0.63. In non enhancing solid portions, three of six cases showed hyperintense to the adjacent peritumoral edema. CONCLUSION: On DWI, the signal intensities of solid portion has positive correlation with malignant potential, and perilesional edema of brain tumors appear various signal intensities owing to "T2 shine through effect" and the extensiveness of vasogenic edema. Another merit using DWI on the evaluation of brain tumors is to improved better delineation of tumor margins from the adjacent edemas, especially at the non enhancing solid portion of the tumors.

Helical CT Cholangiography with Multiplanar Reformation: Utility in Patients with Extrahepatic Biliary Obstruction

PURPOSE: The purpose of this study was to evaluate the utility of the CT cholangiography by using helical CT with multiplanar reformation in patients with extrahepatic biliary obstruction. MATERIALS AND METHODS: Helical CT was performed in 36 patients of extrahepatic biliary obstruction confirmed by operation or invasive cholangiography(percutaneous transhepatic cholangiography or endoscopic retrograde cholagiopancreatography). The cause of obstructions were 18 benign diseases(11 common bile duct stones, four choledochal cysts, three pancreatitis) and 18 malignant diseases(seven common bile duct carcinomas, seven pancreatic head carcinomas, three ampullary carcinomas, one periampullary duodenal carcinoma). After helical scanning through the extrahepatic bile duct, retrospective reconstruction of the helical data was performed. And then, CT cholagiogram was obtained with multiplanar reformation. We evaluated the technical success rate and the accuracy in determinating the level and the cause of the obstruction. We compared findings of the CT cholangiogram with that of operation or invasive cholangiography. RESULTS: In 100%(36/36) of cases, CT cholangiography could be obtained successfully. The accuracy of the CT cholangiography in determinating the level of the obstruction was 100%(11 cases of suprapancreatic duct, 13 cases of intrapancreatic duct, 13 cases of infrapancreatic duct and ampulla), and the accuracy in determinating the cause of the obstruction was 91.7%(all cases of 18 benign diseases, and 15 cases of 18 malignant diseases). CONCLUSION: In evaluating the obstruction of extrahepatic bile ducts, the CT cholangiography by using helical CT with multiplanar reformation is an useful noninvasive method in determinating the level.and the cause of biliary obstruction and therefore could replace t~e invasive cholangiography.