Contrast-Enhanced Ultrasonography in Diagnosing Intravascular Large B-Cell Lymphoma Infiltrating Liver Sinusoids.

BACKGROUND Intravascular large B-cell lymphoma (IVLBCL) is a rare extranodal large B-cell lymphoma characterized by the selective growth of lymphoma cells within vasculature. This presents a diagnostic challenge due to non-specific symptoms and lack of tumor formation. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) provides useful information in diagnosing FDG-avid lymphoma, but is not specific to  IVLBCL. Contrast-enhanced ultrasonography (CEUS) is useful in evaluating focal liver lesions; however, its efficacy in diagnosing IVLBCL involving the liver remains unknown. CASE REPORT We report the case of an 83-year-old woman presenting with fever, pancytopenia, liver dysfunction, and elevated LD and soluble interleukin-2 receptor levels. PET-CT showed multiple uptake lesions in the liver. We performed CEUS with Sonazoid® to evaluate the mass-like lesions; however, no nodular lesions were observed in B mode images. Systemic enhancement was seen in the early phase but no defect was observed in the post-vascular phase. The latter finding suggested preserved Kupffer cells function, excluding tumor-forming lymphoma and liver metastases. Suspecting IVLBCL, we performed a bone marrow examination, which showed sinusoidal infiltration of large neoplastic cells positive for CD20. The patient's condition deteriorated rapidly and she died 2 days after the examination. Autopsy revealed diffuse infiltration of lymphoma cells into liver sinusoids with preserved Kupffer cells, leading to the diagnosis of IVLBCL. CONCLUSIONS Our case shows that CEUS can distinguish IVLBCL from mass-forming lymphoma based on the absence of a defect in the post-vascular phase in a patient with clinically and radiographically suspected lymphoma involving the liver. This can assist clinicians to select appropriate lesions for biopsy.

Treatment of massive hemoptysis after thoracic aortic aneurysm repair.

BACKGROUND: Massive hemoptysis after thoracic aortic aneurysm (TAA) repair is a rare but potentially lethal condition. Endovascular management is a challenging treatment option due to the complexity of culprit vessel access. CASE PRESENTATION: An 81-year-old woman was referred to our hospital with massive hemoptysis. She had a history of graft replacement and thoracic endovascular aortic repair (TEVAR) for dissecting TAA. Computed tomography (CT) showed massive atelectasis with hematoma in the left lower lung lobe adjacent to the descending aortic aneurysm treated with TEVAR. Contrast-enhanced CT revealed a pseudoaneurysm and proliferation of abnormal vessels at the peripheral side of the left pulmonary ligament artery (PLA) in the atelectasis. The PLA continued to the right subscapular artery via a complex collateral pathway. Diagnostic angiography of the right subcapsular artery revealed a pseudoaneurysm and abnormal vessels at the peripheral side of the left PLA with a systemic-pulmonary artery shunt. Transcatheter arterial embolization (TAE) for the left PLA via the collateral pathway with N-butyl cyanoacrylate achieved complete embolization. The patient's hemoptysis was controlled and she was discharged. CONCLUSIONS: Here we presented a case of massive hemoptysis due to PLA disruption that occurred after TAA repair. TAE via a complex collateral pathway is a feasible and effective treatment for hemoptysis, even in patients who have undergone surgical or endovascular TAA repair.

Embolization of Deep Femoral Artery Aneurysm with a Ligated Proximal Artery Using the Direct Percutaneous Puncture Technique.

We report a case of a deep femoral artery aneurysm with a ligated proximal artery that was successfully managed with endovascular therapy. An 84-year-old male was referred to our institute with a history of surgical resection of a left ruptured deep femoral artery aneurysm wherein another aneurysm was found on the peripheral side. Proximal artery ligation of the peripheral lesion was performed. The residual aneurysm had gradually enlarged after surgery, and contrast-enhanced computed tomography showed contrast effects in the aneurysm that extended to the distal artery. The aneurysm was successfully treated by direct percutaneous puncture embolization with N-butyl-cyanoacrylate.

Erratum: Chest CT Findings in Cases from the Cruise Ship "Diamond Princess" with Coronavirus Disease 2019 (COVID-19).

[This corrects the article DOI: 10.1148/ryct.2020200110.].

Chest CT Findings in Cases from the Cruise Ship Diamond Princess with Coronavirus Disease (COVID-19).

PURPOSE: To evaluate the chest CT findings in an environmentally homogeneous cohort from the cruise ship Diamond Princess with coronavirus disease 2019 (COVID-19). MATERIALS AND METHODS: This retrospective study comprised 104 cases (mean age, 62 years ± 16 [standard deviation], range, 25-93 years) with COVID-19 confirmed with reverse-transcription polymerase change reaction findings. CT images were reviewed, and the CT severity score was calculated for each lobe and the entire lung. CT findings were compared between asymptomatic and symptomatic cases. RESULTS: Of 104 cases, 76 (73%) were asymptomatic, 41 (54%) of which had lung opacities on CT. Twenty-eight (27%) cases were symptomatic, 22 (79%) of which had abnormal CT findings. Symptomatic cases showed lung opacities and airway abnormalities on CT more frequently than asymptomatic cases [lung opacity; 22 (79%) vs 41 (54%), airway abnormalities; 14 (50%) vs 15 (20%)]. Asymptomatic cases showed more ground-glass opacity (GGO) over consolidation (83%), while symptomatic cases more frequently showed consolidation over GGO (41%). The CT severity score was higher in symptomatic cases than asymptomatic cases, particularly in the lower lobes [symptomatic vs asymptomatic cases; right lower lobe: 2 ± 1 (0-4) vs 1 ± 1 (0-4); left lower lobe: 2 ± 1 (0-4) vs 1 ± 1 (0-3); total score: 7 ± 5 (1-17) vs 4 ± 2 (1-11)]. CONCLUSION: This study documented a high incidence of subclinical CT changes in cases with COVID-19. Compared with symptomatic cases, asymptomatic cases showed more GGO over consolidation and milder extension of disease on CT.An earlier incorrect version appeared online. This article was corrected on April 8, 2020.© RSNA, 2020.

Numerical Simulation Based on Individual Voxel Phantoms for a Sophisticated Evaluation of Internal Doses Mainly From 131I in Highly Exposed Workers Involved in the TEPCO Fukushima Daiichi NPP Accident.

As a response to the Tokyo Electric Power Company's Fukushima Daiichi nuclear power plant accident in 2011, seven TEPCO workers whose exposure doses were expected to be >250 mSv (a tentative dose limit stipulated by the Japanese central authority) attended Japan's National Institute for Radiological Sciences for additional internal dose measurements. The National Institute for Radiological Sciences examination revealed that these workers' internal doses came mainly from their intake of the radionuclide I during emergency operations. In this study, we performed numerical simulations based on individual volume-pixel (voxel) phantoms of six of the seven workers for a more sophisticated evaluation of their internal doses, taking into account the individual thyroid size and other specific parameters. The voxel phantoms were created from magnetic resonance imaging scan images. As a result, the individual thyroid volumes ranged from 6.5 to 28.2 cm and were considerably smaller than the reference value (~20 cm) adopted in the International Commission on Radiation Protection's dosimetric model for four of the six subjects. Compared to the original estimates of the thyroid absorbed dose, our preliminary evaluation revealed values that were increased by approximately 3-fold or decreased by 30% at maximum. A wide difference in the individual thyroid size would be one of the significant modifiers in the current dose estimation of subjects of the ongoing epidemiological study project. The present simulations also provided evidence that the direct thyroid measurements by the National Institute for Radiological Sciences to determine the workers' I thyroid contents were sufficiently accurate.

AN ACCIDENT OF INTERNAL CONTAMINATION WITH PLUTONIUM AND AMERICIUM AT A NUCLEAR FACILITY IN JAPAN: A PRELIMINARY REPORT AND THE POSSIBILITY OF DTPA ADMINISTRATION ADDING TO THE DIAGNOSIS.

This article introduces the first accident of internal contamination with plutonium (Pu) or americium (Am) in Japan for which treatment was carried out. An accident of internal contamination with Pu and Am occurred at a Pu research facility at Oarai-town of Ibaraki prefecture in Japan. A plastic bag containing these radionuclides ruptured when five workers were inspecting a storage container in a hood. As a consequence, these workers were internally contaminated with Pu and Am. Although contamination on the body surface was observed in all five workers, a positive nasal swab was detected in only three of them. A chelating agent, calcium diethylenetriaminepenta-acetate (CaDTPA), was administered to all of them including the two workers without a positive nasal swab. However, bioassay detected a significant amount of Pu and Am in urine after administration of DTPA in these two workers, whereas the levels of these nuclides were below minimum detectable levels in urine before the administration. Since the prevalence of adverse reactions in DTPAs is low, the present results suggest that administration of DTPA can be used for the diagnosis of internal contamination even when a nasal swab is negative or contamination around body orifices is not detected.

Protective effect of inhalation of hydrogen gas on radiation-induced dermatitis and skin injury in rats.

The effect of inhalation of hydrogen-containing gas (1.3% hydrogen + 20.8% oxygen + 77.9% nitrogen) (HCG) on radiation-induced dermatitis and on the healing of healing-impaired skin wounds in rats was examined using a rat model of radiation-induced skin injury. An X-ray dose of 20 Gy was irradiated onto the lower part of the back through two holes in a lead shield. Irradiation was performed before or after inhalation of HCG for 2 h. Inhalation of HCG significantly reduced the severity of radiodermatitis and accelerated healing-impaired wound repair. Staining with terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) and 8-hydroxy-2(')-deoxyguanosine (8-OHdG) showed that the proportion of apoptotic keratinocytes and the level of staining in the X-irradiated skin of rats that pre-inhaled HCG were significantly lower than that of rats which did not pre-inhale HCG. Cutaneous full-thickness wounds were then created in the X-irradiated area to examine the time-course of wound healing. X-irradiation significantly increased the time required for wound healing, but the inhalation of HCG prior to the irradiation significantly decreased the delay in wound healing compared with the control and post-inhalation of HCG groups. Therefore, radiation-induced skin injury can potentially be alleviated by the pre-inhalation of HCG.

18F-FDG-PET/CT as an indicator for resection of pulmonary epithelioid hemangioendothelioma.

A 60-year-old man with a 7-year history of multiple pulmonary nodules presented to our hospital because the nodules were seen to have increased in size on review of films on a regular medical checkup 1 week earlier. Computed tomography (CT) revealed multiple pulmonary nodules with calcification in the lungs. The largest nodule measuring 2.5 cm in the maximum dimension was lobulated and ill-defined. The patient underwent 18F-fluorodeoxyglucose positron emission tomography/CT (18F-FDG-PET/CT) to evaluate the multiple nodules and to search for a primary lesion. 18F-FDG-PET/CT revealed increased uptake in only two nodules with a standardized uptake value of 4.61 and 2.10, respectively. The two foci with increased 18F-FDG uptake were resected and pathologically proven to be pulmonary epithelioid hemangioendothelioma (PEH). PEH can transform into malignancy with metastasis. An 18F-FDG-PET/CT finding may be an indicator to decide on PEH resection.

[Chronological change in the national health insurance reimbursement based on the DPC package payment system regarding 131I internal therapy].

The national health reimbursement in 131I internal therapy for thyroid cancer and Graves' disease has increased by introducing the DPC package payment system. The thyroid cancer administration fee for shield room should be increased because of the strict regulation for 131I internal therapy, expensive equipments, confinement of radiopharmaceutical supply, and low efficiency in admission to shield rooms. In addition, the Graves' disease administration fee for shield room should be introduced since the inpatients undergo the same administration and care as the thyroid cancer inpatients.

[Statistical study on the self-selection bias in FDG-PET cancer screening by a questionnaire survey].

A questionnaire survey was performed to investigate the possible presence of self-selection bias in 18F-FDG PET cancer screening (PET cancer screening). Responders to the questionnaires survey consisted of 80 healthy persons, who answered whether they undergo PET cancer screening, health consciousness, age, sex, and smoking history. The univariate and multivariate analyses on the four parameters were performed between the responders who were to undergo PET cancer screening and the responders who were not. Statistically significant difference was found in health consciousness between the above-mentioned two groups by both univariate and multivariate analysis with the odds ratio of 2.088. The study indicated that self-selection bias should exist in PET cancer screening.

Clinical significance of the serum IL-2R level and Ga-67 scan findings in making a differential diagnosis between sarcoidosis and non-Hodgkin's lymphoma.

OBJECTIVE: To compare the serum-soluble interleukin-2 receptor (sIL-2R) levels of non-Hodgkin's lymphoma patients and active sarcoidosis patients in relation to the (67)Ga scan findings. METHODS: A total of 29 adenopathy patients suspected of having non-Hodgkin's lymphoma or sarcoidosis were enrolled in the study. All patients underwent a whole-body (67)Ga scan and single-photon emission computed tomography studies 48 h after intravenous injection of (67)Ga citrate. The sIL-2R levels were compared between the sarcoidosis patients and non-Hodgkin's lymphoma patients, the patients with and without the panda and/or lambda sign, the lymphoma patients with stage I/II disease and with stage III/IV disease, and the sarcoidosis patients and non-Hodgkin's lymphoma patients with stage III/IV disease. RESULTS: The range of the sIL-2R levels was 195-3750 U/ml in sarcoidosis and 240-62 300 U/ml in non-Hodgkin's lymphoma. The sIL-2R levels of the six non-Hodgkin's lymphoma patients with stage III/IV disease were significantly higher than those of the 15 sarcoidosis patients (P < 0.001). The sIL-2R levels of the sarcoidosis patients with the panda and/or lambda sign were significantly higher than those with neither sign (P < 0.005). The sIL-2R levels of the non-Hodgkin's lymphoma patients with stage III/IV disease were significantly higher than those of the patients with stage I/II disease (P < 0.005). CONCLUSIONS: Measurement of sIL-2R levels was sometimes useful in differentiating between sarcoidosis and stage III/IV non-Hodgkin's lymphoma, staging non-Hodgkin's lymphoma, and predicting the presence of the panda and/or lambda sign in sarcoidosis patients.

Should mediastinoscopy actually be incorporated into the FDG PET strategy for patients with non-small cell lung carcinoma?

BACKGROUND: Incorporating mediastinoscopy (MS) into the PET-based strategy for non-small cell lung carcinoma (NSCLC) patients might be cost-effective because MS can allow unnecessary thoracotomies to be avoided. The objective of our study was to assess the cost-effectiveness of incorporating MS into a PET strategy for NSCLC patients. METHODS: To determine life expectancy (LE), quality adjusted life years (QALY), and the incremental cost-effectiveness ratio (ICER), a decision-tree sensitivity analysis was designed for histopathologically confirmed NSCLC patients with M0 disease, based on the three competing strategies of chest CT only vs. PET + CT vs. PET + CT + MS. A simulation of 1000 NSCLC patients was created using baselines of other relevant variables in regard to sensitivity, specificity, mortality, LE, utilities and cost from published data. One-way sensitivity analyses were performed to determine the influences of mediastinal metastasis prevalence on LE, QALY and ICER. RESULTS: The LE and QALY per patient in the CT only strategy, PET + CT strategy and PET + CT + MS strategy were 4.79 and 4.35, 5.33 and 4.93 and 5.68 and 5.33 years, respectively, with a 20% prevalence of mediastinal metastasis. The ICERs were 906.6 yen x 10(3) (7555 US dollars)/QALY/patient at a 20% mediastinal metastasis prevalence, and 2194 yen x 10(3) (18,282 US dollars)/QALY/patient at a 50% prevalence, but exceeded 5280 yen x 10(3) (44,000 US dollars)/QALY/ patient at 80%. CONCLUSIONS: Our study quantitatively showed the CT + PET + MS strategy in place of the PET + CT strategy in managing NSCLC patients to be cost-effective. MS should be incorporated into the PET + CT strategy for NSCLC patients except in those highly suspected of having mediastinal disease on chest CT or PET.

Honda sign and variants in patients suspected of having a sacral insufficiency fracture.

PURPOSE: The purpose of this study was to reassess whether the Honda sign (HS) and its variants on bone scans can be used to differentiate an insufficiency fracture (IF) of the sacrum from a metastasis and to evaluate extrapelvic tracer accumulation in patients suspected of having a sacral IF. METHODS AND MATERIALS: We retrospectively reviewed 34 bone scans of 26 patients suspected of having a sacral IF between January 1998 and June 2003. RESULTS: Twenty-four of the patients had a sacral IF and 1 had a sacral metastasis from prostate cancer and another from lung cancer. The bone scans of only 15 (63%) of the 24 patients with a sacral IF exhibited the HS, 8 (33%) scans exhibited variants, and 4 (4%) scans showed whole-sacrum uptake. One of the 2 patients with metastasis exhibited the HS and the other exhibited a variant. The sensitivity and positive predictive value of HS plus its variants as diagnostic criteria for sacral IF were 96% and 92%, respectively. Seventeen patients (71%) had extrasacral accumulation. The most common site was the pubic bone (50%, 12 of 24), and the second most common site was the spine (46%, 11 of 24), where the accumulation was the result of a compression fracture or degenerative joint disease of the spine. CONCLUSIONS: A "Honda sign or variation" with evidence of fractures elsewhere or no evidence of other metastatic disease should be strong evidence for a sacral insufficiency fracture. The likelihood of having a solitary metastasis to the sacrum is small.

[Changes in national insurance reimbursement with introduction of the DPC package payment system for 131I therapy for hyperthyroidism].

The inpatient DPC package payment system lowers national insurance reimbursement as compared to the former fee-for-service payment system for inpatients, when an inpatient with hyperthyroidism or toxic multinodular goiter (TMNG) is admitted for 2-day radioiodine therapy. The differentials are 29,970 yen and 48,870 yen for a 2-day hospital stay for administration of 555 MBq and 925 MBq, respectively. We request the Health and Labor Ministry to newly establish the fee for 131I internal therapy for hyperthyroidism. Furthermore, the fee should be paid according to the fee-for-service payment system.

Görög Thrombosis Test: a global in-vitro test of platelet function and thrombolysis.

This is the first laboratory evaluation of a new instrument, designed to test both platelet function and thrombolytic activity from a native blood sample, in vitro. The inventor assumed that the reduction and arrest of blood flow was due to activation, aggregation and stabilized thrombus formation by shear-activated platelets, and that re-establishment of flow was due to thrombolysis. Morphologic and functional studies presented here confirm these mechanisms. In vitro tests provided incontestable evidence for the principal role of platelets in the obstruction of flow (occlusion time) and for thrombolysis as the principal mechanism underlying the restoration of blood flow (lysis time). In addition to aggregation, it is the explosive generation of thrombin by shear-activated platelets that results in the formation of an occlusive haemostatic thrombus. Anticoagulation of blood completely prevented occlusion. Platelet-rich thrombus formation (occlusion time) was dose-dependently inhibited by monoclonal antibody against platelet glycoprotein (GP) Ib (6B4 and 12E4), aurin tricarboxylic acid, monoclonal antibody against platelet GPIIb/IIIa (MA-16N7C2 and abciximab), a synthetic GPIIb/IIIa antagonist (TAK-029), thrombin inhibitor (argatroban), and anti-von Willebrand factor, but not by anti-fibrinogen. Plasminogen activator streptokinase (Varidase) and tissue-type plasminogen activator (Monteplase) dose-dependently enhanced thrombolysis (lysis time) without affecting platelet function (occlusion time). The test is specific for thrombolysis. The plasmin inhibitor tranexamic acid prevented plasminogen activator-induced thrombolysis, while inhibition of clot retraction by cytochalasin B did not affect the lysis time. This rapid and sensitive global test of platelet function and thrombolytic activity could be of great value both in research and in clinical practice.

Enhancement of endogenous plasminogen activator-induced thrombolysis by argatroban and APC and its control by TAFI, measured in an arterial thrombolysis model in vivo using rat mesenteric arterioles.

Recent in vitro studies have demonstrated that thrombin inhibits fibrinolysis through thrombin-activatable fibrinolysis inhibitor (TAFI, plasma procarboxypeptidase B). We have recently shown that endogenous fibrinolysis in vivo is enhanced by activated protein C (APC) and the selective thrombin inhibitor, argatroban. The aim of the present study was to examine the role of TAFI in these fibrinolytic mechanisms in vivo using purified porcine pancreatic carboxypeptidase B (PPCPB) and a specific TAFIa inhibitor, potato tuber carboxypeptidase B inhibitor (PTCI) in a newly established arterial thrombolysis model. Non-occlusive, mural, platelet-rich thrombi were formed by helium-neon laser irradiation in rat mesenteric arterioles and thrombus size was measured by computerised image analysis. We confirmed that endogenous thrombolysis was enhanced by argatroban (2.0 mg/4 ml/kg/h) or APC (1.62 mg/ 2.31 ml/kg). PTCI (5.0 mg/2 ml/kg) also accelerated endogenous thrombolysis. PPCPB (3.5 mg/2 ml/kg) inhibited thrombolysis in the absence and presence of argatroban or APC. PTCI tended to further promote APC-induced thrombolysis but the differences did not reach statistical significance. The present findings were in keeping with the results of earlier studies and demonstrated that arterial, platelet-rich thrombi in vivo are degraded by naturally generated plasminogen activators. TAFI may play a significant role in the control of these mechanisms.

The haemagglutinin of Clostridium botulinum type C progenitor toxin plays an essential role in binding of toxin to the epithelial cells of guinea pig small intestine, leading to the efficient absorption of the toxin.

Binding of the purified type C 7S (neurotoxin), 12S and 16S botulinum toxins to epithelial cells of ligated small intestine or colon of the guinea pig (in vivo test) and to pre-fixed gastrointestinal tissue sections (in vitro test) was analysed. The 16S toxin bound intensely to the microvilli of epithelial cells of the small intestine in both in vivo and in vitro tests, but did not bind to cells of the stomach or colon. The neurotoxin and 12S toxin did not bind to epithelial cells of the small intestine or to cells of the stomach or colon. Absorption of the toxins was assessed by determining the toxin titre in the sera of guinea pigs 6-8 h after the intra-intestinal administration of the toxins. When the 16S toxin [1 x 10(5) minimum lethal dose (MLD)] was injected, 200-660 MLD ml-1 was detected in the sera, whereas when the 12S toxin (2 x 10(5) MLD) or 7S toxin (2 x 10(5) MLD) was injected, little toxin activity was detected in the sera. Therefore, the haemagglutinin of type C 16S toxin is apparently very important in the binding and absorption of botulinum toxin in the small intestine.