A case of an advanced renal collecting duct carcinoma in which initial therapeutic effect was achieved with pembrolizumab plus axitinib.

Introduction: Renal collecting duct carcinoma is often found in advanced cancers and has a poor prognosis. Here, we present the case of symptomatic metastatic collecting duct carcinoma in which we observed an initial therapeutic effect of immune checkpoint inhibitors plus tyrosine kinase inhibitors. Case presentation: The patient was a 69-year-old male who was referred to our hospital for examination of a right chest tumor and related pain. Contrast-enhanced computed tomography and tumor biopsy were performed, leading to a diagnosis of collecting duct carcinoma. A combination of pembrolizumab plus axitinib was initiated as first-line therapy; right chest pain decreased, and tumor shrinkage was observed. Seven months after treatment initiation, tumor progression was noted. Cabozantinib was initiated as second-line therapy; however, was discontinued due to patient fatigue. The patient died 15 months after the initiation of treatment. Conclusion: For symptomatic metastatic collecting duct carcinoma, pembrolizumab plus axitinib may have initial therapeutic effects.

[NONRISING BLADDER PARAGANGLIOMA SUCCESSFULLY TREATED BY THE OPEN BLADDER SURGERY: A CASE REPORT].

The patient is a 47-year-old female. MRI revealed a well-defined submuscular mass in the bladder muscle layer. Bladder paraganglioma was suspected based on MRI findings. Endocrinologic Testing showed no significant elevation. 123I-MIBG scintigraphy of the mass showed a significant uptake, and we made diagnosis of bladder paraganglioma. The mass was nonrising and showed no color differentiation making its location undetectable. Using MRI with a ureteral stent and urethral catheter in place, we were able to determine its location. The possibility of damage to the ureteral or internal urethral opening was feared. We chose open bladder surgery, emphasizing ease of operation and visualization. Although a transient increase in blood pressure was observed during the operation, the mass was resected as a single mass from all layers of the bladder without damaging the ureteral or internal urethral opening. Histopathological examination revealed a paraganglioma.MRI (ureteral stent and urethral catheter placement) and open bladder surgery were useful for identifying the location and resecting this case of this otherwise undetectable bladder paraganglioma.

[LAPAROSCOPIC LIVE DONOR NEPHRECTOMY WITH HORSESHOE KIDNEY: A CASE REPORT].

We performed laparoscopic live donor nephrectomy (LDN) on approximately 200 patients in Ehime Prefectural Center Hospital between 2003 and 2016. In 2016, a fifty-something woman who was a donor candidate for her husband was revealed to have a horseshoe kidney through contrast-enhanced computed tomography; other LDN procedures used a retroperitoneal approach, but this one used a transperitoneal approach since the latter approach allowed for a more favorable visual field. The left kidney was selected since renal scintigraphy showed equal bilateral renal function and renal arteries are simpler on the left side. The kidney was removed after the isthmus was successfully transected without ischemia. The opened calyx in the left kidney was sutured via bench surgery, and the kidney was transplanted to the recipient. Postoperative courses of both donor and recipient were good.

Clinical significance of ultrasonographic imaging of the common hepatic arterial lymph node (No. 8 LN) in chronic liver diseases.

In chronic liver diseases, the size of the portal lymph node and the common hepatic arterial lymph node (No. 8a LN) is often altered. The objective of this study was to investigate the relationship between the pathology of chronic liver diseases and the common hepatic arterial lymph nodes using an ultrasonographic diagnostic system. The subjects included 115 patients with hepatitis C (chronic hepatitis C, 75; liver cirrhosis C, 40), 31 patients with hepatitis B (chronic hepatitis B, 17; liver cirrhosis B, 14), 16 patients with primary biliary cirrhosis (PBC), 11 patients with autoimmune hepatitis (AIH), 29 patients with alcoholic hepatitis (Alc.LD) and 190 healthy adults with no abnormalities in liver function or inflammatory reactions (100 males and 90 females, age range 26-71 years, mean 49.2). The long and short axes of No. 8 LN were measured, and the value calculated by multiplying the two diameters was designated as the LN index (Fig. 1). The No. 8 LN appearance rate and LN index were significantly higher in the patients with hepatitis C, PBC and AIH than in the healthy subjects. When the LN index cut-off value was set to 50, alanine aminotransferase and aspartate aminotransferase were significantly higher in chronic hepatitis C (CHC) patients than in the healthy subjects. In addition, the LN and splenic indexes were significantly correlated in CHC patients, suggesting that the LX index is related to portal pressure increase with an elevation of sinusoidal pressure. The LN index after interferon therapy was significantly lower in complete responders than in non-responders. The No. 8 LN index may be closely related to the pathology of chronic liver diseases.

Corona enhancement in ultrasonographical post-vascular phase images with microbubble contrast agent: a novel specific sign for hepatocellular carcinomas.

In 1.5 Harmonic Imaging ultrasonography (1.5 HI US), images are obtained in a band intermediate between the fundamental and 2nd harmonic components, resulting in stronger contrast enhancement than in conventional harmonic imaging. We attempted to assess the hemodynamics of hepatocellular carcinomas (HCC) with special attention to blood drainage using 1.5 HI US. Forty-two HCC nodules, metastatic liver tumors and hepatic hemangiomas were studied. In contrast studies, intermittent ultrasound transmission was performed for a period of up to 45 sec after the injection of contrast agent, which was regarded as the vascular phase. The time point of 5 min later was specified as the post-vascular phase, and images were obtained by single manual transmission for comparison of contrast enhancement with surrounding hepatic parenchyma. In addition, histological examination was performed. 1.5 HI US clearly demonstrated the strong tumor vessels in most HCCs. Corona enhancement, in which the areas surrounding the tumor are enhanced, was observed in 71.4% (30/42) of HCC nodules during the post-vascular phase. This sign was not observed in any other tumors. Histological findings revealed that CD34-positive-endothelial cells were prominent in the surrounding area of HCC. In conclusion, 1.5 HI US is an effective tool for evaluating hemodynamics in both early- and post-vascular phase. Corona enhancement may be due to the trapping of contrast agent in the endothelial cells in the surround of HCC nodules and be a novel specific sign for HCC.

1.5 Harmonic Imaging Sonography with microbubble contrast agent improves characterization of hepatocellular carcinoma.

AIM: To investigate the usefulness of 1.5 Harmonic Imaging Sonography with the use of the contrast agent Levovist for the diagnosis of hepatocellular carcinoma (HCC) and for the evaluation of therapeutic response. METHODS: Phantom experiments were performed to compare the contrast effects of 2(nd) harmonic imaging and 1.5 Harmonic Imaging Sonography. 1.5 Harmonic Imaging Sonography was employed to examine 36 patients with HCC (42 nodules) before and after the treatment and to compare against the findings obtained using other diagnostic imaging modalities. RESULTS: In 1.5 Harmonic Imaging Sonography, the tumor vessels of HCCs were clearly identified during the early phase, and late-phase images clearly demonstrated the differences in contrast enhancement between the tumor and surrounding hepatic parenchyma. Blood flow within the tumor was detected in 36 nodules (85.7%) during the early phase and in all 42 nodules (100%) during the late phase using 1.5 Harmonic Imaging Sonography, in 38 nodules (90.5%) using contrast-enhanced CT, in 34 nodules (81.0%) using digital subtraction angiography (DSA), and in 42 nodules (100%) using US CO(2) angiography. Following transcatheter arterial embolization, 1.5 Harmonic Imaging Sonography detected blood flow and contrast enhancement within the tumors that were judged to contain viable tissue in 20 of 42 nodules (47.6%). However, 6 of these 10 cases were not judged in contrast-enhanced CT. 1.5 Harmonic Imaging Sonography was compared with the US CO(2) angiography findings as the gold standard, and the sensitivity and specificity of these images for discerning viable and nonviable HCC after transcatheter arterial embolization were 100% and 100%, respectively. CONCLUSION: 1.5 Harmonic Imaging Sonography permits the vascular structures of HCCs to be identified and blood flow within the tumor to be clearly demonstrated. Furthermore, 1.5 Harmonic Imaging Sonography is potentially useful for evaluating the therapeutic effects of transcatheter arterial embolization on HCC.

The usefulness of 1.5 harmonic imaging ultrasonography with Levovist in the diagnosis of focal hepatic tumors.

In contrast-enhanced 1.5 harmonic imaging sonography, images are obtained in a band intermediate between the fundamental and the 2nd harmonic components. In the present study, we investigated the usefulness of 1.5 harmonic imaging sonography with the use of the contrast agent Levovist for the diagnosis of hepatocellular carcinoma (HCC), metastatic hepatic tumor, and hepatic hemangioma. The subjects in this study were 64 patients with 70 nodules of hepatic tumors (42 nodules in 36 cases of hepatocellular carcinoma, 20 nodules in 20 cases of metastatic hepatic tumor, and 8 nodules in 8 cases of hepatic hemangioma). Contrast enhancement of tumors acquired in the early, portal, and late phases with 1.5 harmonic imaging sonography were compared to classify the tumors. 1.5 harmonic imaging sonography of HCC showed contrast enhancement of 36 nodules (85.7%). Hypervascular enhancement in the early phase, which was maintained in the portal phase, changed to images with no contrast enhancement with partial persistence of contrast enhancement in the late phase. 1.5 harmonic imaging sonography of metastatic hepatic tumor showed hypervascular enhancement of the margin of 20 nodules (100%) in the early and portal phases, which changed to images with no contrast enhancement in the late phase. 1.5 harmonic imaging sonography of hepatic hemangiomas maintained hypervascular enhancement on the tumor margin of 5 nodules (62.5%) in the early and portal phases. When early phase 1.5 harmonic imaging sonography did not show hypervascular enhancement in 3 nodules (37.5%), and late-phase images confirmed that these 3 nodules were hypervascular enhancement on the tumor margin. 1.5 harmonic imaging sonography of hepatic tumors (hepatocellular carcinoma, metastatic hepatic tumor and hepatic hemangioma) provided characteristic findings of contrast enhancement in the early, portal, and late phases, and will contribute to differential diagnosis.

Basket pattern blood flow signals discovered in a case of splenic hamartoma by power Doppler ultrasonography.

We present the gray-scale ultrasonography (GSUS), power Doppler ultrasonography (PDUS), abdominal computed tomography (CT), and magnetic resonance imaging (MRI) findings for a case of splenic hamartoma in a 27-year-old man, showing a phi 50 mm homogeneous, iso- and hypo-echoic splenic mass with evidence of a small plural cystic lesion. This splenic hamartoma showed increased vascularity on power Doppler sonograms. PDUS showed multiple circular blood flow signals inside the mass (i.e. a basket pattern), which was consistent with the small plural cystic lesion shown by GSUS. Spectral analysis also confirmed arterial and venous flow. CT scans showed that the mass had low-density relative to the normal spleen and MRI showed that the mass was isodense, relative to the normal spleen. Therefore, CT and MRI are not useful for the diagnosis of splenic hamartoma. Ultrasonography can be used to diagnose splenic hamartoma without administration of a contrast material and therefore is an indispensable method for the diagnosis of splenic hamartoma.

An anomaly in persistent right umbilical vein of portal vein diagnosed by ultrasonography.

AIM: To detect the anomaly in the persistent right umbilical vein (PRUV) of portal vein (PV) with deviation of the ligamentum tere and left-sided gallbladder. METHODS: A total of 5783 candidates for routine analysis were evaluated for hepatic vascular abnormalities by ultrasonography. RESULTS: Ten candidates (0.17%) had a portal vein anomaly with a rightward-deviated ligamentum tere. The blood-flow velocity in the PRUV of the portal vein (17.7+/-3.0 cm/s) of the 10 cases was similar to that of the right anterior portal trunk (17.6+/-4.1 cm/s). However, the vessel diameter of the PRUV (eta12.4+/-4.4 mm) was larger than the right anterior portal trunk (eta6.1+/-0.9 mm). Therefore, flow volume in the anomalous portion (0.97+/-0.30 L/min) was more than that in the right anterior portal trunk (0.18+/-0.05 L/min). CONCLUSION: The anomaly plays an important role in intra-hepatic PV flow.

Hemodynamics in the portal vein evaluated by pulse wave Doppler ultrasonography in patients with chronic hepatitis C treated with interferon.

AIM: To employ pulse wave Doppler ultrasonography to evaluate the changes in portal blood flow velocity in patients with chronic hepatitis C (CHC) receiving interferon (IFN) treatment. METHODS: The subjects in this study were 14 patients (13 men and 1 woman) with CHC who received IFN treatment. Portal blood flow velocity was measured in the vessels at the porta hepatis at four time points: before IFN administration (pre-IFN), 2 wk after the start of administration (wk 2), 24 wk after the start of administration (wk 24, i.e., the end of IFN administration), and 24 wk after the end of administration (wk 48). RESULTS: The patients with CHC in whom IFN treatment resulted in complete elimination or effective elimination of viruses showed a significant increase in portal blood flow velocity at the end of IFN treatment compared with that before IFN treatment. In contrast, when IFN was ineffective, no significant increase in portal blood flow velocity was observed at wk 24 or 48 compared with the pre-IFN value. In addition, the patients with CHC in whom IFN was ineffective showed significantly lower portal blood flow velocity values than control subjects at all measurement time points. CONCLUSION: Pulse wave Doppler ultrasonography is a noninvasive and easily performed method for evaluating the effects of IFN treatment in patients with CHC. This technique is useful for measuring portal blood flow velocity before and 24 wk after IFN administration in order to evaluate the changes over time, thus assessing the effectiveness of IFN treatment.

Usefulness of digital subtraction imaging with Levovist in the diagnosis of hepatocellular carcinomas.

To classify hepatocellular carcinoma (HCC) based on the findings of digital subtraction imaging (DSI) and to compare DSI against other diagnostic imaging modalities to assess its reliability DSI was performed in 68 patients with HCC (72 nodules) and the enhancement patterns of blood flow in the tumor were assessed during the early phase, the portal phase and the late phase. In addition, the findings obtained by DSI were compared with those obtained by helical CT, digital subtraction angiography (DSA), CO2 angiography and CT during arterial portography (CTAP). Of the 72 nodules, blood flow was detected in 64 (88.9%) by early-phase DSI, in 61 (84.7%) by helical CT, in 62 (86.1%) by DSA and in 67 (93.1%) by CO2 angiography. Early-phase DSI did not demonstrate hypervascular enhancement in 8 HCC nodules (16.7%). These included 5 nodules in which other diagnostic imaging modalities also failed to identify tumor blood vessels and 3 nodules located in deep regions 87.5 mm or more from the body surface. With regard to these 5 nodules (10.4%) in which tumor vessels were not visualized during the early phase, late-phase DSI demonstrated relatively poor enhancement compared with normal hepatic parenchyma. Such late-phase defects in tumor enhancement were observed in 69 nodules (95.8%). DSI demonstrated characteristic findings of HCC enhancement during the early phase, the portal phase and the late phase, permitting classification of HCC to be performed.

Early graft hemodynamics in living related liver transplantation evaluated by Doppler ultrasonography.

The aim of this study was to clarify the perioperative hemodynamics of liver grafts without vascular complications during and early after liver transplantation from living donors. This study was carried out in 4 child recipients (lateral segment left lobe grafts) and 6 adult recipients (right lobe grafts) of liver transplantation from living donors. The hemodynamics of the hepatic artery, portal vein, and hepatic vein of the grafts during and until 7 days after surgery were studied by Doppler ultrasonography. The maximum flow velocity of the hepatic artery, mean portal blood flow velocity, and pulsatility index (PI) of the hepatic artery increased in all 10 grafts with no vascular complication after vascular anastomosis. After surgery, the mean portal blood flow velocity showed a peak 3 days after surgery and reached a nadir 7 days after surgery in both the lateral segment left lobe grafts in children and the right lobe grafts in adults, but it was significantly higher in the right lobe grafts in adults (mean +/- SD 31.0 +/- 6.3 vs. 22.4 +/- 0.9 cm/sec). Also, as the hepatic artery blood flow velocity increased the portal blood flow velocity decreased, the hepatic blood flow during liver regeneration was suggested to be controlled by both the artery and portal vein. The range of PI of the hepatic artery was 0.60-1.86. The mean hepatic venous blood flow was stable throughout the observation period (30.4 +/- 8.8 cm/sec). Although the hepatic venous flow waves changed widely from pulsed waves to a flat flow, its changes did not suggest a vascular complication. Evaluation of changes by Doppler ultrasonography in the hemodynamics of the liver grafts without vascular complications during and early after liver transplantation from living donors is considered to be useful for accurate monitoring of the hemodynamics during liver regeneration and early detection of abnormalities.

The usefulness of digital subtraction imaging with Levovist in the diagnosis of focal hepatic tumors.

This study was designed to evaluate digital subtraction imaging (DSI) with Levovist in the diagnosis of hepatocellular carcinoma (HCC), metastatic hepatocellular carcinoma, and hepatic hemangioma. The subjects in this study were 70 patients with 76 nodules of hepatic tumors (48 nodules in 46 cases of hepatocellular carcinoma, 20 nodules in 16 cases of metastatic hepatocellular carcinoma, and 8 nodules in 8 cases of hepatic hemangioma). Contrast enhancement of tumors acquired in the early, portal, and late phases with DSI were compared to classify the tumors. DSI of HCC showed contrast enhancement of 40 nodules (82.2%). High contrast enhancement in the early phase, which was maintained in the portal phase, changed to images with no contrast enhancement with partial persistence of contrast enhancement in the late phase. DSI of metastatic hepatic carcinomas demonstrated contrast enhancement of tumor of 18 nodules (90%) to a high degree in the early and portal phases, which changed to images with no contrast enhancement in the late phases. DSI of hepatic hemangioma maintained high contrast enhancement on tumor margins of 5 nodules (62.5%) and on the entire tumor of 3 nodules (37.5%) in the early, portal, and late phases. DSI of hepatic tumors (hepatocellular carcinoma, metastatic hepatocellular carcinoma, and hepatic hemangioma) provided characteristic findings of contrast enhancement in the early, portal, and late phases, and contribute to differential diagnosis.

The effect of endoscopic injection sclerotherapy on portal blood flow and liver function.

BACKGROUND/AIMS: It is still controversial whether endoscopic injection sclerotherapy can affect portal blood flow and liver function. To clarify this issue, we investigated the change in portal blood flow velocity and the relationship between liver function and portal blood flow after sclerotherapy. METHODOLOGY: Ten liver cirrhosis patients with F2 esophageal varices were enrolled in this study. All patients underwent sclerotherapy until all varices were eradicated. Portal blood flow velocity was measured using Doppler ultrasonography. The changes in laboratory parameters and the portal flow velocity were analyzed in each patient. RESULTS: Total mean portal blood flow velocity was changed from 7.5 +/- 5.3 cm/s to 10.3 +/- 3.5 cm/s by sclerotherapy. Six of ten cases had increase in portal blood flow velocity. Among them, 5 cases demonstrated improvement in serum albumin and total cholesterol level 3 months after sclerotherapy. CONCLUSIONS: Prophylactic endoscopic injection sclerotherapy among patients with early liver cirrhosis can improve liver function by increasing the portal blood flow.