Current staging of hepatocellular carcinoma: imaging implications.

The incidence of hepatocellular carcinoma has been rising in the USA in the past two decades. Hepatocellular carcinoma primarily affects older people and reaches its highest prevalence among those aged between 50 and 70 years. Chronic infection by the hepatitis B virus is the most common cause of this disease. Since hepatocellular carcinoma is an indolent tumor, it has a low life expectancy. In patients with suspected hepatocellular carcinoma, CT, MRI, and ultrasound techniques are useful for formulating the diagnosis based on vascularity and specific enhancement features. In this paper we will discuss the multimodal approach for diagnosis and surveillance of hepatocellular carcinoma. We will also furnish the latest staging and treatment, epidemiology, clinical presentation, pathology and laboratory findings in hepatocellular carcinoma.

Use of thin-section, multidetector row helical CT images for coronal oblique reformations for optimal visualization of structures in the hepatoduodenal ligament.

Multidetector row computed tomography (CT) can acquire abdominal images of unprecedented thinness in a single breath-hold. This study investigated whether acquiring source axial images at 1.25 mm as opposed to 2.5 mm would result in a perceptible difference in image quality for coronal oblique reformations. Similarly, the hypothesis that a slice pitch of 3:1 would be superior to 6:1 was evaluated. Twenty-nine CT studies were retrospectively evaluated. The images were divided into four groups: 1.25-mm axial images, pitch 3:1; 2.5-mm axial images, pitch 3:1; 1.25-mm axial images, pitch 6:1; and 2.5-mm axial images, pitch 6:1. Three radiologists evaluated by consensus the coronal oblique reformations for overall image quality and image quality of structures in the hepatoduodenal ligament and of nodal groups. Use of 1.25-mm rather than of 2.5-mm source axial images resulted in statistically significant better scores for overall image quality and visualization of the hepatic artery, portal vein, pancreatic duct, and nodal groups. However, a pitch of 3:1 rather than of 6:1 did not result in significant differences in ratings of image quality. Use of 1.25-mm rather than of 2.5-mm source axial images improves image quality when creating coronal oblique reformations for abdominal anatomy.

Evidence that F-plasmid proteins TraV, TraK and TraB assemble into an envelope-spanning structure in Escherichia coli.

We have examined the role of the F-plasmid TraV outer membrane lipoprotein in the assembly of F-pili. Yeast two-hybrid analysis with a traV bait repeatedly identified traK, which is predicted to encode a periplasmic protein, among positive prey plasmids. A traK bait in turn identified traV and traB, which is predicted to encode an inner membrane protein. A traB bait exclusively identified traK preys. Several additional observations support the hypothesis that TraV, TraK and TraB form a complex in Escherichia coli that spans the cell envelope from the outer membrane (TraV) through the periplasm (TraK) to the inner membrane (TraB). First, two-hybrid analyses indicated that TraV and TraB bind to different TraK segments, as required if TraK bridges a ternary complex. Secondly, all three proteins fractionated with the E. coli outer membrane in tra+ cells. In contrast, TraB fractionated with the inner membrane in traV or traK mutant cells, and TraK appeared in the osmotic shock fluid from the traV mutant. These results are consistent with a TraV-TraK-TraB complex anchored to the outer membrane via the TraV lipoprotein. Further, in traK mutant cells, TraV failed to accumulate to a detectable level, and the TraB level was significantly reduced, suggesting that TraV and TraB must interact with TraK for either protein to accumulate to its normal level. Both TraK and TraV accumulated in traB2[Am] cells; however, the TraB2 amber fragment could be detected by Western blot, and sequence analysis indicated that the fragment retained the TraK-binding domain suggested by yeast two-hybrid analysis. We propose that TraV is the outer membrane anchor for a trans-envelope, Tra protein structure required for the assembly of F-pili and possibly for other events of conjugal DNA transfer.

Interaction between the F plasmid TraA (F-pilin) and TraQ proteins.

Elaboration of conjugative (F) pili by F+ strains of Escherichia coli requires the activities of over a dozen F-encoded DNA transfer (Tra) proteins. The organization and functions of these proteins are largely unknown. Using the yeast two-hybrid assay, we have begun to analyse binary interactions among the Tra proteins required for F-pilus formation. We focus here on interactions involving F-pilin, the only known F-pilus subunit. Using a library of F tra DNA fragments that contained all the F genes required for F pilus formation in a yeast GAL4 activation domain vector (pACTII), we transformed yeast containing a plasmid (pAS1CYH2traA) encoding a GAL4 DNA-binding domain-F-pilin fusion. Doubly transformed cells were screened for GAL4-dependent gene expression. This screen repeatedly identified only a single Tra protein, TraQ, previously identified as a likely F-pilin chaperone. The F-pilin-TraQ interaction appeared to be specific, as no transcriptional activation was detected in yeast transformants containing pACTIItraQ plasmids and the Salmonella typhi pED208 traA gene cloned in pAS1CYH2. Two traQ segments isolated in the screen against F-pilin were tested for complementation of a traQ null allele in E. coli. One, lacking the first 11 (of 94) TraQ amino acids, restored DNA donor activity, donor-specific bacteriophage sensitivity and membrane F-pilin accumulation to wild-type levels. The second, lacking the first 21 amino acids, was much less effective in these assays. Both TraQ polypeptides accumulated in E. coli as transmembrane proteins. The longer, biologically active segment was fused to the GAL4 DNA-binding domain gene of pAS1CYH2 and used to screen the tra fragment library. The only positives from this screen identified traA segments. The fusion sites between the traA and GAL4 segments identified the hydrophobic, C-terminal domain IV of F-pilin as sufficient for the interaction. As TraQ is the only Tra protein required for the accumulation of inner membrane F-pilin, the interaction probably reflects a specific, chaperone-like function for TraQ in E. coli. Attempts to isolate an F-pilin-TraQ complex from E. coli were unsuccessful, suggesting that the interaction between the two is normally transient, as expected from previous studies of the kinetics of TraA membrane insertion and processing to F-pilin.

Tuberculosis versus lymphomas in the abdominal lymph nodes: evaluation with contrast-enhanced CT.

OBJECTIVE: Tuberculosis in the abdominal lymph nodes may be difficult to distinguish from lymphomas. This study evaluated specific CT imaging criteria for differentiating these entities. MATERIALS AND METHODS: We retrospectively reviewed the anatomic distribution and CT enhancement patterns of disease in 69 patients, 26 (38%) with tuberculosis and 43 (62%) with untreated lymphomas involving abdominal lymph nodes. Of the patients with tuberculosis, five (19%) had disseminated disease and 21 (81%) had nondisseminated disease. Of the patients with lymphomas, 16 (37%) had Hodgkin's disease and 27 (63%) had non-Hodgkin's lymphoma. RESULTS: Disseminated and nondisseminated tuberculosis involved predominantly lesser omental, mesenteric, anterior pararenal, and upper paraaortic lymph nodes. Lower paraaortic lymph nodes were involved more often in Hodgkin's disease (15 patients [94%]), non-Hodgkin's lymphoma (24 patients [89%]), and disseminated tuberculosis (five patients [100%]) than in nondisseminated tuberculosis (one patient [5%]). Mesenteric lymph nodes were involved more often in disseminated tuberculosis (four patients [80%]) and nondisseminated tuberculosis (11 patients [52%]) than in Hodgkin's disease (one patient [6%]) (p < .01). Anatomic distribution was not different between disseminated tuberculosis and non-Hodgkin's lymphoma. Tuberculous lymphadenopathy commonly showed peripheral enhancement, frequently with a multilocular appearance, whereas lymphomatous adenopathy characteristically showed homogeneous attenuation (14 patients [87.5%] with Hodgkin's disease and 19 patients [70%] with non-Hodgkin's lymphoma [p < .01]). CONCLUSION: Our findings indicate that the anatomic distribution and specific enhancement patterns of lymphadenopathy seen on contrast-enhanced CT can be useful in differentiating between tuberculosis and untreated lymphomas of the abdominal lymph nodes.

Peak enhancement of the liver in children using power injection and helical CT.

OBJECTIVE: Our objective was to determine the level and timing of peak hepatic enhancement in children using power injection of contrast media, helical CT, and computer-automated scan technology. SUBJECTS AND METHODS: Forty-nine abdominal CT studies were performed using computer-automated scan technology. Patients were divided into four groups on the basis of body weight and contrast dose (group 1A, < or = 20 kg and 2 ml/kg; group 1B, < or = 20 kg and 3 ml/kg; group 2, 21-40 kg and 2 ml/kg; group 3, > 40 kg and < or = 2 ml/kg). Contrast injection rates were based on body weight (groups 1A and 1B, 1 ml/sec; group 2, 1.5 ml/sec; and group 3, 2 ml/sec). The peak hepatic enhancement level in Hounsfield units and the time to reach peak enhancement were determined for each patient. RESULTS: The mean peak hepatic enhancement and time to peak enhancement after completion of contrast injection were group 1A, 45 H and 11 sec; group 1B, 62 H and 3 sec; group 2, 52 H and 12 sec; and group 3, 45 H and 10 sec. CONCLUSION: The level and timing of peak hepatic enhancement in pediatric patients can be obtained using computer-automated scan technology. These data may then be used to optimize hepatic enhancement when obtaining helical abdominal CT scans of pediatric patients.

Imaging of the liver with helical CT: a survey of scanning techniques.

OBJECTIVE: We conducted a survey of the members of the Society of Computed Body Tomography/Magnetic Resonance to assess current techniques in liver imaging using helical CT. MATERIALS AND METHODS: The survey, which was designed to update earlier surveys from 1987 and 1993, included a questionnaire distributed to 77 members of the Society of Computed Body Tomography/Magnetic Resonance. RESULTS: Forty-nine members responded, representing 28 institutions. In 1993, 19% (5/26) of institutions used helical scanners, compared with 82% (23/28) in 1996. The group of institutions with helical CT served as the focus of this survey. In 1993, 58% of institutions used 1-cm collimation: in 1996, 78% (18/23) used thinner, 7- to 8-mm collimation. In 1987, 41% used power injectors compared with 85% in 1993 and 100% in 1996. In 1996, monophasic injections were used by 96% (22/23) of institutions. In 1993, most institutions used a contrast material injection rate of 1.5-2.0 ml/sec; in 1996, most used a 2.5-3.0 ml/sec injection rate. In 1993, 96% of institutions used 125-150 ml of contrast material; in 1996, 57% (13/23) of institutions used 125-150 ml and 30% of institutions used less than 125 ml of contrast material. A delay time of 21-45 see was used by 83% of institutions in 1993, whereas in 1996, 83% (19/23) of institutions used a longer delay time of 50-80 sec. In 1996, 13% of institutions used an individual scan delay technology and all institutions performed multiphasic scanning of hypervascular lesions. CONCLUSION: The availability of helical CT has changed radiologists' approach to liver imaging. The greatest effects of which are a more widespread use of power injectors, longer delay times, thinner collimation, increased contrast material injection rates, decreased contrast material volumes, and multiphasic scanning.

TNM staging of pancreatic carcinoma using helical CT.

OBJECTIVE: The purpose of this study was to determine the accuracy of helical CT scanning in predicting the stage of carcinoma of the exocrine pancreas using TNM staging guidelines and in predicting resectability of carcinoma of the exocrine pancreas. MATERIALS AND METHODS: Twenty-six patients with proven adenocarcinoma of the pancreas underwent uniphasic or biphasic helical CT scanning. Two observers unaware of the patient's surgical stage evaluated the CT examinations using the TNM system (with specific assessment and description of disease sites). In addition, the two observers rated confidence of nonresectability using a 5-point scale (ranging from 1, definitely resectable, to 5, definitely not resectable). Observer results and preoperative interpretations were compared with surgical findings. RESULTS: Nineteen of 26 patients had nonresectable disease. The combined observer scores showed correct determination of T stage in 77% of patients, of N stage in 58%, and of M stage in 79%. The overall accuracy in determining lack of resectability was 96% and 84% for the two observers. All errors in determining resectable versus nonresectable disease occurred when the observer was not maximally confident of his or her diagnosis. CONCLUSION: Helical CT is an effective screening technique for assessing T and M stages of pancreatic carcinoma. However, helical CT is poor at detecting regional lymph node involvement. In patients with equivocal T-stage findings (such as questionable venous involvement), other studies such as endoscopic sonography may be of value.

Evaluation of an approach to choosing a left double-lumen tube size based on chest computed tomographic scan measurement of left mainstem bronchial diameter.

OBJECTIVE: Evaluation of an approach to choosing left double-lumen tube size based on chest computed tomographic (CT) scan measurement of left bronchial diameter. DESIGN: Prospective. SETTING: The operating rooms of a university hospital. PARTICIPANTS: Patients scheduled for elective thoracic surgery. INTERVENTIONS: Patients had their left bronchial diameter measured on the preoperative chest CT scan. Left double-lumen tube size for the individual patient was chosen from a protocol based on left bronchial diameter. MEASUREMENTS AND MAIN RESULTS: The double-lumen tube size was considered appropriate for the patient if some air leak was detected when the bronchial cuff was deflated and if airtight seal of the left bronchus was obtained with a bronchial cuff volume of 2 mL or less. In 17 of 20 patients, the double-lumen tube size fulfilled both criteria. In 3 women with left bronchi measuring 10 mm or less, the bronchus was sealed without any air in the bronchial cuff of size 35 Fr left double-lumen tubes. In 1 patient, who was excluded from the study, the double-lumen tube size was chosen based on measurement of the left bronchial diameter on chest radiograph because of motion artifact on the chest CT scan. CONCLUSIONS: Chest CT scan measurement of left bronchial diameter can successfully guide the choice of left double-lumen tube size for an individual patient. In individuals with a small left bronchus measuring less than 10.0 mm in diameter, currently available adult double-lumen tube sizes will tightly wedge in their bronchus.

The greater omentum.

Understanding the embryologic development, anatomic relationships, and pathologic processes of the greater omentum is critical to its complete and proper evaluation. The broad spectrum of imaging findings presented in this essay may allow readers to appreciate features that aid accurate diagnosis of omental disease.

Towards a structural biology of bacterial conjugation.

Horizontal DNA transfer among bacteria (conjugation) requires the formation of secure intercellular contacts before DNA transfer can occur. The formation of such contacts among Gram-negative bacteria is mediated by conjugative pili. Like other pili, conjugative pili are filaments extending from the surface of donor cells. They are composed, in so far as is known, entirely of conjugative pilin subunits. Here, we review the structure of F-pilin, the subunit of which F-pili are composed. We emphasize recent studies suggesting a specific domain organization for F-pilin and present a model of how these domains might be arranged in filament subunits.

Effect of traY amber mutations on F-plasmid traY promoter activity in vivo.

We have examined the effect of the F plasmid TraY protein on tra gene expression in vivo. Expression was assayed as alkaline phosphatase activity in cells containing a traY phi(traA'-'phoA)hyb operon under traY promoter control. Amber mutations in traY significantly reduced alkaline phosphatase activity. Since nonsense polarity effects were minimal, if they occurred at all, these data provide the first direct evidence that TraY regulates tra gene expression.

Helical CT of renal masses: the value of delayed scans.

OBJECTIVE: Routine scanning techniques used for helical CT of the abdomen result in dense cortical opacification of the kidney, whereas the medulla and collecting system are not well opacified, which potentially compromises detection of renal masses. The purpose of this retrospective study was to determine if additional delayed views (taken approximately 2-4 min after the start of injection of contrast material) are necessary for the detection and characterization of renal masses. MATERIALS AND METHODS: Early (60-70 sec after the start of the injection of contrast material) and delayed scans of 40 patients with suspected renal masses were blindly evaluated by two observers. The patients harbored a total of 187 renal masses (including 62 solid masses). Each region of the kidney (upper, middle, and lower pole) was scored for the presence of a mass. Scoring was done as a binary decision and also as a five-point confidence score for receiver operating characteristic analysis. RESULTS: We found 97 regions that contained renal masses and 114 regions that did not. Receiver operating characteristic analysis revealed the observers to have significantly greater confidence in detection of renal masses on the delayed scans. The binary data showed the two observers to have a sensitivity of 97% for delayed scans versus 77% (p = .0002) and 89% (p = .027), respectively, for the early scans. For the first observer, early and delayed scans were of equal specificity, but for the second observer, the delayed scans yielded greater specificity (94% versus 85%, p = .024). On the early scans, both observers were significantly more likely to miss a neoplastic lesion than a nonneoplastic lesion. The less experienced of the two observers also tended to have greater difficulty in characterizing the lesions on the early scans. CONCLUSION: Because of the significant risk of missing a renal mass, especially a neoplasm, on early cortical-phase scans, additional delayed scans appear justified when a renal mass is suspected on the basis of other imaging tests or clinical history.

Assessment of a technology that permits individualized scan delays on helical hepatic CT: a technique to improve efficiency in use of contrast material.

OBJECTIVE: We performed this study to assess the usefulness of a computer automated scan technology (CAST) for individualizing scan delay during helical CT to improve the efficiency of hepatic enhancement. SUBJECTS AND METHODS: We prospectively evaluated 183 patients who were randomized into five groups. Control patients received 100 or 150 ml of contrast material (320 mg I/ml) with a 60-sec delay between contrast injection at 3 ml/sec and scanning. CAST patients received 100, 125, or 150 ml. In our latter groups we used an hepatic enhancement threshold of 50 H over baseline to determine the optimum delay between contrast injection and scanning. For the intergroup comparisons, we measured the liver on baseline and enhanced helical CT scans at the upper, mid, and lower levels of the liver. RESULTS: The mean enhancement in patients who received 150 ml of contrast material was 70.7 +/- 19.4 H for the control group and 81.0 +/- 17.5 H for the CAST group (p < .05). Hepatic enhancement above 50 H was achieved in 84% of the control subjects compared with 100% of CAST subjects; more than 60 H hepatic enhancement was achieved in 73% of control subjects and in 89% of CAST subjects. The use of CAST software with 125-ml contrast doses provided enhancement equivalent to that of control subjects who received 150 ml of contrast material (mean enhancement in CAST subjects, 70.3 +/- 15.4 H). Enhancement above 50 H was reached in 98% of CAST and 84% of control patients. With 100 ml of contrast material, 24% of patients failed to initiate CAST, resulting in enhancement similar to control patients (CAST, 54.2 +/- 11.4 H; controls, 56.9 +/- 15.2 H). CONCLUSION: Using a contrast dose of 150 ml, CAST provided significantly increased hepatic enhancement than that achieved in control subjects with less variability. For equivalent hepatic enhancement, contrast doses could be decreased by 25 ml using CAST technology because it provides individualized scan delays.