A case of pseudo-Kaposi sarcoma with chronic limb-threatening ischemia.

BACKGROUND: Pseudo-Kaposi sarcoma (PKS) is a rare vascular proliferative disease, caused by arteriovenous malformation (AVM) and chronic venous insufficiency. The lesions are characterized by purple or reddish-brownish papules, plaques, and nodules. Although benign, it is clinically similar to Kaposi's sarcoma (KS), a malignant disease, and must be differentiated by histopathological examination. We report a rare case of PKS with chronic limb-threatening ischemia (CLTI). CASE PRESENTATION: An 83-year-old man with diabetes mellitus (DM) presented to a local dermatology department with a complaint of a right second toe ulcer and was, thereby, referred to our department due to arterial bleeding during skin biopsy to exclude malignant diseases. Although the pulsation of dorsalis pedis artery of the affected limb was palpable, the skin perfusion pressure was only 20 and 30 mmHg on the dorsum and planter surface, respectively, indicating severe ischemia of toe and forefoot. Ultrasonography and computed tomography revealed an AVM around the right second metatarsophalangeal joint and occlusion of the right dorsalis pedis artery in the middle, indicating CLTI in the background. Pathological findings of the skin biopsy found capillary blood vessel proliferation, hemosiderin deposition, and extravascular red blood cell leakage in the dermal layer, which could be found in KS. However, CD34 was normally stained in the vascular endothelium, and human herpesvirus-8 staining was negative, resulting in the pathological diagnosis of PKS, a proliferative vascular lesion associated with AVM. The ulcer was spontaneously epithelialized, but 2 years later the ulcer recurred and infection developed, necessitating treatment for abnormal blood flow. Transarterial embolization using N-butyl 2-cyanoacrylate for the AVM controlled abnormal perfusion once; however, the procedure exacerbated perfusion of the toe, resulting in foot ulcer progression. Forefoot amputation with surgical excision of AVM was performed, and thereby, wound healing was achieved. CONCLUSION: This is a rare case of PKS with CLTI complicated with AVM. As there is currently no established consensus on the treatment of PKS, the approach to treatment strategy should be tailored to the specific condition of each patient.

Inter- and intra-rater reproducibility of quantitative T1 measurement using semiautomatic region of interest placement in myometrium.

PURPOSE: This study aimed to investigate the inter- and intraobserver reproducibility of quantitative T1 (qT1) measurements using manual and semiautomatic region of interest (ROI) placements. We hypothesized the usefulness of the semiautomatic method, which utilizes a three-dimensional (3D) anatomical relationship between the myometrium and other tissues, for minimizing ROI placement variation, thereby improving qT1 reproducibility compared to the manual approach. The semiautomatic approach, which considered anatomical relationships, was expected to enhance reproducibility by reducing ROI placement variabilities. MATERIALS AND METHODS: This study recruited 23 healthy female volunteers. Data with variable flip angle (VFA) and inversion recovery were acquired using 3D-spoiled gradient echo and spin echo sequences, respectively. T1 maps were generated with VFA. Manual and semiautomatic ROI placements were independently conducted. Mean qT1 values were calculated from the T1 maps using the corresponding pixel values of the myometrial ROI. Inter- and intraobserver reproducibility of qT1 values was investigated. The inter- and intraobserver reproducibility of qT1 values was evaluated by calculating the coefficient of variation (CoV). Further, reproducibility was evaluated with inter- and intraobserver errors and intraclass correlation coefficients (ICCs). Bland-Altman analysis was utilized to compare the results, estimate bias, and determine the limits of agreement. RESULTS: The mean inter- and intraobserver CoV of the qT1 values for semiautomatic ROI placement was significantly lower than those for manual ROI placement (p < 0.05 and p < 0.01, respectively). ICCs for semiautomatic ROI placement were greater than those for manual ROI placement. Further, the mean inter- and intraobserver errors for semiautomatic ROI placement were significantly lower than those for manual ROI placement (p < 0.05 and p < 0.01, respectively). CONCLUSION: Semiautomatic ROI placement demonstrated high reproducibility of qT1 measurements compared with manual methods. Semiautomatic ROI placement may be useful for evaluating uterine qT1 with high reproducibility.

Epipericardial Fat Necrosis: A Retrospective Analysis in Japan.

Objective Epipericardial fat necrosis (EFN) has been considered to be a rare cause of acute chest pain, and especially important for emergency physicians. Chest computed tomography (CT) is often used for the diagnosis of EFN after excluding life-threatening states, such as acute coronary syndrome and pulmonary embolism. While the proportion of EFN patients who underwent chest CT in emergency departments is being clarified, little is still known about other departments in Japan. To investigate the proportion of EFN patients who underwent chest CT for acute chest pain in various departments. Methods Chest CT performed from January 2015 to July 2020 in Asahikawa Medical University Hospital in Japan was retrospectively analyzed in this study. All images were reviewed by two radiologists. Results There were 373 outpatients identified by a search using the word 'chest pain' who underwent chest CT. Eight patients satisfying the imaging criteria were diagnosed with EFN. The proportions of patients diagnosed with EFN were 10.7%, 4.8%, 2.8%, 0.9% and 0% in the departments of general medicine, cardiovascular surgery, emergency medicine, cardiovascular internal medicine and respiratory medicine, respectively. Only 12.5% of the patients were correctly diagnosed with EFN, and the other patients were treated for musculoskeletal symptoms, acute pericarditis or hypochondriasis. Conclusion EFN is not rare and is often overlooked in various departments. All physicians as well as emergency physicians should consider the possibility of EFN as the cause of pleuritic chest pain.

Damage control surgery for grade IV blunt hepatic injury with multiple organ damage in a child: a case report.

BACKGROUND: Intra-abdominal hemorrhage caused by blunt hepatic injury is a major cause of morbidity and mortality in patients with abdominal trauma. Some of these patients require laparotomy, and rapid decision-making and life-saving surgery are essential. Damage control (DC) surgery is useful for treating children in critical situations. We performed this technique to treat an 8-year-old boy with grade IV blunt hepatic injury and multiple organ damage. This is the first report of the use of the ABTHERA Open Abdomen Negative Pressure Therapy System (KCI, now part of 3 M Company, San Antonio, TX, USA) for DC surgery to rescue a patient without neurological sequelae. CASE PRESENTATION: An 8-year-old boy was brought to the emergency department of our hospital after being run over by a motor vehicle. He had grade IV blunt hepatic injury, thyroid injury, and bilateral hemopneumothorax. Although he was hemodynamically stable, the patient's altered level of consciousness, the presence of a sign of peritoneal irritation, and suspicion of intestinal injury led us to perform exploratory laparotomy. As part of a DC strategy, we performed gauze packing to control hemorrhage from the liver and covered the abdomen with an ABTHERA Open Abdomen Negative Pressure Therapy System to improve the patient's general condition. Eighteen days after admission, the patient was diagnosed with a biliary fistula, which improved with percutaneous and external drainage. He had no neurological sequelae and was discharged 102 days after injury. CONCLUSION: The DC strategy was effective in children with severe blunt hepatic injury. We opted to perform DC surgery because children have less hemodynamic reserve than adults, and we believe that using this strategy before the appearance of trauma triad of death could save lives and improve outcomes. During conservative management, it is important to adopt a multistage, flexible approach to achieve a good outcome.

Severe liver injury with traumatic cardiac arrest successfully treated by damage control surgery and transcatheter arterial embolization in the hybrid operating room: a case report.

BACKGROUND: The damage control approach is known to reduce the mortality rate in severely injured patients and has now become a common practice. Transcatheter arterial embolization (TAE) has been shown to be useful with combining with damage control laparotomy in identifying and controlling active arterial hemorrhage. Hybrid operating room (OR) allows both damaged control surgery and TAE in the same location in minimal time. We report a case of a patient with three cardiac arrests who was saved by early intervention using damage control surgery (DCS) with interventional radiology (IVR) in the hybrid OR. CASE PRESENTATION: A 46-year-old woman was injured in a collision with a tree while snowboarding. She was eventually transported to hybrid operating room in our hospital with the diagnosis of significant liver laceration and hemorrhagic shock. Damage control surgery was performed with perihepatic packing (PHP) and TAE was conducted to stop active bleeding from right hepatic artery. She experienced 3 times of cardiopulmonary arrest, which was successfully resuscitated on each occasion. Although she had total of 3 times of laparotomy but tolerated well. She was discharged on day 82 of hospitalization and showed no neurological sequelae. CONCLUSION: Saving the life of a patient with severe trauma requires a multidisciplinary approach with cooperation and early information sharing among trauma team members. Sharing treatment strategy with the trauma team and early intervention using DCS with IVR in the hybrid operating room could save the patient's life.

Roles of the apparent diffusion coefficient and tumor volume in predicting tumor grade in patients with choroid plexus tumors.

PURPOSE: To explore the utility of the apparent diffusion coefficient (ADC) and tumor volume to predict histological grade and prognosis in patients with choroid plexus tumors. METHODS: ADC and tumor volumes were retrospectively evaluated in 25 patients with choroid plexus papilloma (CPP; WHO grade 1 [n = 13]), atypical CPP (aCPP; grade 2 [n = 8]), or choroid plexus carcinoma (grade 3 [n = 4]) The prognostic roles of ADC and tumor volume were assessed. RESULTS: There were significant differences in mean and minimum ADC values, and tumor volume among the WHO grades (p = 0.033, p = 0.044, and p = 0.014, respectively). Receiver-operating characteristic analysis revealed a mean cutoff ADC value ≤ 1.397 × 10-3 mm2/s for aCPP (sensitivity = 0.667, specificity = 0.923). Multiple linear regression analysis demonstrated that both mean ADC (ß = - 0.455, p = 0.005) and tumor volume (ß = 0.513, p = 0.002) were correlated with WHO grade (adjusted R2 = 0.520, p = 0.005). Kaplan-Meier curve analysis identified poorer survival in patients with WHO grade 2 and 3 tumors than in those with WHO grade 1 disease (p = 0.049 and p = 0.012, respectively). A mean ADC ≤ 1.397 × 10-3 mm2/s (p = 0.001) and tumor volume 21.05 ml (p = 0.031) predicted significantly poorer survival. CONCLUSION: Mean ADC and tumor volume were correlated with WHO grade of choroid plexus tumors. A lower ADC value and a larger tumor volume predicted a poorer prognosis.

Improved detectability of thromboses of the lower limb using low kilovoltage computed tomography.

To determine the utility of low kilovoltage computed tomographic venography (CTV) for the detection of deep venous thrombus in the lower limbs.Twenty-one thrombi in 19 enrolled patients were investigated in this retrospective study. Patients were initially scanned using CTV at 100 kVp, at the femur level, followed by an immediate switch to 80 kVp. We assessed the CT values of thrombi and veins and performed subjective evaluation for detecting thrombi using a 5-point scoring system: 1, unable to evaluate due to noise or artifacts; 2, equivocal venous thrombus; 3, possible venous thrombus; 4, probable venous thrombus; and 5, definite venous thrombus.Venous density on 100-kVp images (mean ±â€ŠSD [standard deviation]: 122 ±â€Š23 HU, 95% confidence interval [CI]: 111-133 Hounsfield unit [HU]) was significantly lower than that on 80-kVp images (136 ±â€Š24 HU, 95% CI: 125-147 HU, P < .001). There was no significant difference in thrombi between 100-kVp images (55 ±â€Š14 HU, 95% CI: 49-61 HU) and 80-kVp images (57 ±â€Š16, 95% CI: 50-64 HU, P = .168). The thrombus to vein ratio on 100-kVp images (0.47 ±â€Š0.20, 95% CI: 0.39-0.56) was significantly higher than that on 80-kVp images (0.44 ±â€Š0.16, 95% CI: 0.37-0.51, P = .048). The mean 5-point score was significantly higher on the 80-kVp images (4.76) than on the 100-kVp images (4.45, P = .016).Lower kilovoltage CTV significantly improved thrombotic to venous contrasts in the lower limbs.

SUV navigator enables rapid [18F]-FDG PET/CT image interpretation compared with 2D ROI and 3D VOI evaluations.

PURPOSE: Positron emission tomography (PET) and the maximum standardized uptake value (SUVmax) is a useful technique for assessing malignant tumors. Measurements of SUVmax in multiple lesions per patient frequently require many time-consuming procedures. To address this issue, we designed a novel interface named SUV Navigator (SUVnavi), and the purpose of this study was to investigate its utility. MATERIALS AND METHODS: We measured SUVmax in 661 lesions from 100 patients with malignant tumors. Diagnoses and SUVmax measurements were made with SUVnavi, 2D, and 3D measurements. SUV measurement accuracy in each method were also evaluated. RESULTS: The average reduction in time with SUVnavi versus 2D was 53.8% and 3D was 37.5%; time required with SUVnavi was significantly shorter than with 2D and 3D (P < 0.001 and P < 0.001, respectively). The time reduction and lesion number had a positive correlation (P < 0.001 and P < 0.001, respectively). SUVmax agreed with precise SUVmax in all lesions measured with SUVnavi and 3D but in only 466 of 661 lesions (70.5%) measured with 2D. CONCLUSION: SUVnavi may be useful for rapid [18F]-fluorodeoxyglucose positron emission tomography/computed tomography ([18F]-FDG PET/CT) image interpretation without reducing the accuracy of SUVmax measurement.

A Quantitative Evaluation of Hepatic Uptake on I-131 Whole-Body Scintigraphy for Postablative Therapy of Thyroid Carcinoma.

This study aimed to determine clinical association between quantitative hepatic uptake on postablative whole-body scan (WBS) with differentiated thyroid cancer (DTC) prognosis. We analyzed 541 scans of 216 DTC patients who were divided into 3 groups based on radioactive iodine (I-131) WBS uptake and clinical follow-up: group 1 (completion of ablation), group 2 (abnormal uptake in the cervical region), and group 3 (abnormal uptake with distant metastases). For each group, we calculated the ratio of I-131 WBS hepatic uptake (H) to cranial uptake as background (B); this ratio was defined as H/B. Furthermore, we made a distinction between group 1, as having completed radioactive iodine therapy (RIT) (CR), and group 2 and 3, as requiring subsequent RIT (RR). The average H/B scores were 1.34 (median, 1.36; range 1.00-2.1) for group 1; 1.89 (median, 1.75; range 1.41-4.20) for group 2; and 2.09 (median, 1.90; range 1.50-4.32) for group 3. Bonferroni multiple comparisons revealed significant differences in H/B among these groups. The H/B of group 1 was significantly smaller than that of other 2 groups (P < 0.0001). The precise cutoff value of H/B for therapeutic effect was ≤1.5. Moreover, 159 of 160 scans in the CR and 375 of 381 patients in the RR were correctly diagnosed using this cutoff value in the final outcome of RIT, yielding a sensitivity, specificity, positive predictive value, and negative predictive value of 99.4%, 98.4%, 99.7%, and 96.3%, respectively. Increased hepatic uptake of I-131 on WBS may predict disease-related progression.

Non-contrast-enhanced computed tomography attenuation in the parotid glands before radioiodine therapy for thyroid carcinoma could be a predictor of radiovulnerability.

OBJECTIVE: This study aimed to determine a predictive factor for the effect of radioiodine therapy (RIT) on salivary gland dysfunction through a multiple regression analysis. METHODS: We retrospectively assessed 40 patients with thyroid carcinoma, including 13 men (age range, 21-80 years) and 27 women (age range, 28-75 years), who underwent total thyroidectomy and were treated with RIT. We used multiple regression analysis to evaluate whether factors such as age, sex, dose number, prescintigraphy grade, computed tomography (CT) attenuation, and CT volume of the salivary glands affected the postscintigraphy grade. Receiver operating characteristics analysis was performed for predicting worsening scintigraphy grade of the parotid glands in 20 patients after RIT. RESULTS: The postscintigraphy grade of the parotid glands was positively associated with the dose number and prescintigraphy grade and negatively associated with CT attenuation (ß=0.48, P<0.01; ß=0.47, P<0.01; and ß=-0.26, P<0.05, respectively; adjusted R2=0.50, P<0.05). In the submandibular glands, the postscintigraphy grade was only positively correlated with dose number (ß=0.58, P<0.01; adjusted R=0.32, P<0.01). Area under the curve was 0.775 (P<0.05) and the cutoff CT attenuation was -18.8 HU (sensitivity 0.714 and specificity 0.846). CONCLUSION: The RIT dose number, prescintigraphy grade, and CT attenuation may be important predictors of parotid gland dysfunction after RIT, whereas the dose number alone may be a significant predictor of submandibular gland dysfunction.

Dual-time-point F-18 FDG PET/CT imaging for differentiating the lymph nodes between malignant lymphoma and benign lesions.

PURPOSE: The purpose of the present study is to evaluate the clinical value of dual-time-point F-18 FDG PET/CT imaging to differentiate malignant lymphoma (ML) from benign lymph node (BLN). MATERIALS AND METHODS: The subjects were 310 lymph nodes in 84 patients (195 ML lesions in 30 patients and 115 BLN in 54 patients associated with various etiologies.). F-18 FDG PET/CT scan was performed at 50 min (early scan) and at 100 min (delayed scan) after the injection. First, the maximum standardized uptake value (SUVmax) of each lesion at early and delayed scans was calculated. Second, we estimated the difference between early and delayed SUVmax (D-SUVmax) and the retention index (RI-SUVmax) to evaluate the change of tracers in the lesions. Furthermore, proper cut-off values of them were evaluated using receiver operating characteristic analysis. The efficacy of each parameter was analyzed with ANOVA. RESULTS: Delayed SUVmax and D-SUVmax in ML were significantly higher than those in BLN. Proper cut-off value in delayed SUVmax was 4.0 and in D-SUVmax was 1.0. When the proper cut-off value in D-SUVmax was applied, the D-SUVmax yielded the role of diagnosis with sensitivity of 82.6%, specificity of 65.2%, positive predictive value of 80.1% and negative predictive value of 68.8%, respectively. CONCLUSIONS: The delayed SUVmax and D-SUVmax were useful indices to differentiate ML from BLN, regardless of histologic subtype. Dual-time-point F-18 FDG PET/CT imaging may help to consider whether there is any need to proceed to more invasive tests, such as biopsy, in individual patients.

"Hot" vertebra on (18)F-FDG PET scan: a case of vertebral hemangioma.

An F-FDG-PET with CT scan was performed to stage a tongue cancer, revealing the hypermetabolic region in the thoracic vertebra. This corresponded to a benign lesion seen on MRIs and CT.Although these findings suggested a vertebral hemangioma, "hot" vertebra in FDG-PET was atypical. The final diagnosis was confirmed capillary hemangioma by the scopic biopsy and this lesion was no change at 1 year later.Careful interpretation of metabolic (FDG-PET) and anatomic (CT and MRI) images should be performed to accurately characterize the foci of increased FDG uptake.