Transcatheter Arterial Embolization for Gastrointestinal Bleeding Secondary to Gastrointestinal Lymphoma

Purpose

To evaluate the effectiveness of transcatheter arterial embolization (TAE) for gastrointestinal (GI) bleeding caused by GI lymphoma.

Materials and Methods

The medical records of 11 patients who underwent TAE for GI bleeding caused by GI lymphoma between 2001 and 2015 were reviewed retrospectively.

Results

A total of 20 TAE procedures were performed. On angiography, contrast extravasation, and both contrast extravasation and tumor staining were seen in 95 % (19/20) and 5 % (1/20) of the procedures, respectively. The most frequently embolized arteries were jejunal (n = 13) and ileal (n = 5) branches. Technical and clinical success rates were 100 % (20/20) and 27 % (3/11), respectively. The causes of clinical failure in eight patients were rebleeding at new sites. In four patients who underwent repeat angiography, the bleeding focus was new each time. Three patients underwent small bowel resection due to rebleeding after one (n = 2) or four (n = 1) times of TAEs. Another two patients underwent small bowel resection due to small bowel ischemia/perforation after three or four times of TAEs. The 30-day mortality rate was 18 % due to hypovolemic shock (n = 1) and multiorgan failure (n = 1).

Conclusion

Angiogram with TAE shows limited therapeutic efficacy to manage GI lymphoma-related bleeding due to high rebleeding at new sites. Although TAE can be an initial hemostatic measure, surgery should be considered for rebleeding due to possible bowel ischemic complication after repeated TAE procedures.

     

Performance of Screening Mammography: A Report of the Alliance for Breast Cancer Screening in Korea

ObjectiveTo analyze the diagnostic accuracy and trend in screening mammography in Korea.ResultsWe enrolled 128756 cases from 10 hospitals from 2005 to 2010. The recall rate was 19.1% with a downward trend over time (-12.1% per year; 95% CI, -15.9 to -8.2). The CDR was 2.69 per 1000 examinations, without a significant trend. The PPV was 1.4% with an upward trend (20.8% per year; 95% CI, 15.2 to 26.7). The sensitivity was 86.5% without a significant trend, whereas the specificity was 81.1% with an upward trend (3.3% per year; 95% CI, 2.1 to 4.5). The FPR was 18.9% with a downward trend (-12.4% per year; 95% CI, -16.2 to -8.4). The ICR was 0.5 per 1000 negative examinations without a significant trend. There were institutional variations in the diagnostic accuracy and trend except for the CDR, sensitivity, and ICR.ConclusionThe sensitivity and CDR of screening mammography in the ABCS-K from 2005 to 2010 were compatible with those for Western women. The recall rate, PPV and specificity, however, were suboptimal, although they showed significant improvements over this period. A further analysis is required to explain institutional variations.     

High-Resolution MRI Findings following Trigeminal Rhizotomy

BACKGROUND AND PURPOSE:Patients with trigeminal neuralgia often undergo trigeminal rhizotomy via radiofrequency thermocoagulation or glycerol injection for treatment of symptoms. To date, radiologic changes in patients with trigeminal neuralgia post-rhizotomy have not been described, to our knowledge. The aim of this study was to evaluate patients after trigeminal rhizotomy to characterize post-rhizotomy changes on 3D high-resolution MR imaging.MATERIALS AND METHODS:A retrospective review of trigeminal neuralgia protocol studies was performed in 26 patients after rhizotomy compared with 54 treatment-naïve subjects with trigeminal neuralgia. Examinations were reviewed independently by 2 neuroradiologists blinded to the side of symptoms and treatment history. The symmetry of Meckel''s cave on constructive interference in steady-state and the presence of contrast enhancement within the trigeminal nerves on volumetric interpolated breath-hold examination images were assessed subjectively. The signal intensity of Meckel''s cave was measured on coronal noncontrast constructive interference in steady-state imaging on each side.RESULTS:Post-rhizotomy changes included subjective clumping of nerve roots and/or decreased constructive interference in steady-state signal intensity within Meckel''s cave, which was identified in 17/26 (65%) patients after rhizotomy and 3/54 (6%) treatment-naïve patients (P < .001). Constructive interference in steady-state signal intensity within Meckel''s cave was, on average, 13% lower on the side of the rhizotomy in patients posttreatment compared with a 1% difference in controls (P < .001). Small regions of temporal encephalomalacia were noted in 8/26 (31%) patients after rhizotomy and 0/54 (0%) treatment-naïve patients (P < .001).CONCLUSIONS:Post-trigeminal rhizotomy findings frequently include nerve clumping and decreased constructive interference in steady-state signal intensity in Meckel''s cave. Small areas of temporal lobe encephalomalacia are encountered less frequently.

Trigeminal neuralgia is a debilitating condition characterized by sharp pain in the distribution of the trigeminal nerve. First described in 1773 by John Fothergill, trigeminal neuralgia is now a widely recognized and frequently encountered condition with a prevalence as high as 200/100,000 individuals and an overall incidence of 2.7/100,000/year.^1–5 First-line treatment commonly consists of medical management with carbamazepine, followed by additional second- and third-line medical treatments.^1,6 If medical management fails, imaging of the trigeminal nerves is often performed to assess causes such as compression of the cisternal segment of the trigeminal nerve from vascular structures or, less commonly, mass lesions along the course of this nerve.Trigeminal rhizotomy, which is performed by percutaneous insertion of a needle through the foramen ovale into Meckel''s cave to damage the nerve by balloon compression, glycerol injection, or radiofrequency thermocoagulation, is often performed as a first-line procedure and may be the only procedure available to patients unable to undergo the more invasive surgical intervention of microvascular decompression. Microvascular decompression is an invasive method of treatment with reported higher patient satisfaction and an overall lower symptom recurrence rate compared with rhizotomy, but it requires an open neurosurgical approach.^7,8High-resolution MR imaging of the trigeminal nerves has allowed radiologists to see the cisternal and Meckel''s cave segments of the trigeminal nerve with exquisite detail. In particular, constructive interference in steady-state (CISS) imaging, a free precession technique with intrinsic flow suppression and high signal-to-noise ratio, allows visualization of fine structures, including individual rootlets of the trigeminal nerve in Meckel''s cave. We have also observed that CISS is sensitive to small perturbations in the content of fluid and can demonstrate reduced signal compared with CSF, even when differences are not visualized on spin-echo-based imaging. Because patients can have high-resolution imaging after trigeminal rhizotomy for a number of indications, including recurrence of symptoms, the goal of this study was to determine the findings expected on postprocedural imaging following percutaneous rhizotomy.Given the postulated mechanism of action of rhizotomy—that is, changes in osmolarity and resulting demyelination and neurolysis with glycerol or direct heat neurolysis with radiofrequency thermocoagulation—we hypothesized the following: the rootlets of the trigeminal nerve in the region of the injection would demonstrate visible changes in their course due to clumping and adhesion; and the signal on CISS imaging would be reduced within Meckel''s cave due to injectate and/or inflammatory debris.⁹ In addition, we sought to evaluate whether enhancement of the trigeminal nerve or Meckel''s cave should be expected following rhizotomy. The rates of other changes to surrounding structures and the muscles of mastication that are innervated by the mandibular division of the trigeminal nerve (cranial nerve V.3) were recorded.     

Gadobenate dimeglumine-enhanced liver MR imaging in cirrhotic patients: quantitative and qualitative comparison of 1-hour and 3-hour delayed images

Purpose:

To compare the image quality and diagnostic performance of 1‐ and 3‐h delayed‐phase MR images (DPIs) after gadobenate dimeglumine injection in detecting small hepatocellular carcinomas (HCCs) in cirrhotic patients.

Materials and Methods:

Relative enhancement of the liver (RE_liver) and HCC (RE_HCC) and liver‐to‐lesion contrast‐to‐noise ratio (CNR) of HCC were measured quantitatively on 1‐ and 3‐h DPIs in 65 patients with 88 HCCs. For qualitative analysis, two radiologists independently evaluated three image sets in 19 patients with 25 HCCs ≤2 cm and in 16 controls without HCCs: conventional liver MR without DPI (set A), adding 1‐h DPI (set B), and adding 3‐h DPI (set C), using a 5‐point scale for diagnosing small HCCs. Diagnostic performance for small HCCs was analyzed using the alternative free‐response receiver operating characteristic method.

Results:

Mean RE_liver (P = 0.013) and RE_HCC (P < 0.001) were significantly higher on 1‐h than on 3‐h DPI, whereas CNR was significantly higher on 3‐h than on 1‐h DPI (P = 0.001). Observer‐averaged figure of merit (FOM) was significantly higher for set C than for set A (0.942 versus 0.883; P = 0.013).

Conclusion:

In cirrhotic patients, 3‐h DPI provides a higher liver‐to‐lesion contrast and a better diagnostic performance for small HCCs than 1‐h DPI. J. Magn. Reson. Imaging 2011;33:889–897. © 2011 Wiley‐Liss, Inc.     

Effect of chelator conjugation level and injection dose on tumor and organ uptake of 111In-labeled MORAb-009, an anti-mesothelin antibody

Introduction

Radiolabeling of a monoclonal antibody (mAb) with a metallic radionuclide requires the conjugation of a bifunctional chelator to the mAb. The conjugation, however, can alter the physical and immunological properties of the mAb, consequently affecting its tumor-targeting pharmacokinetics. In this study, we investigated the effect of the amount of 2-(p-isothiocyanatobenzyl)-cyclohexyl-diethylenetriamine-pentaacetic acid (CHX-A″) conjugated to MORAb-009, a mAb directed against mesothelin, and the effect of MORAb dose on the biodistribution of ¹¹¹In-labeled MORAb-009.

Methods

We used nude mice bearing the A431/K5 tumor as a mesothelin-positive tumor model and the A431 tumor as a mesothelin-negative control. To find the optimal level of CHX-A″ conjugation, CHX-A″-MORAb-009 conjugates with 2.4, 3.5 and 5.5 CHX-A″ molecules were investigated. To investigate the effect of injected MORAb-009 dose on neutralizing the shed mesothelin in the circulation, biodistribution studies were performed after the intravenous co-injection of ¹¹¹In-labeled MORAb-009 (2.4 CHX-A″/MORAb-009) with three different doses: 0.2, 2 and 30 μg of MORAb-009.

Results

The tumor uptake in A431/K5 tumor was four times higher than that in A431 tumor, indicating that the tumor uptake in A431/K5 was mesothelin mediated. The conjugate with 5.5 CHX-A″ showed a lower isoelectric point (pI) and lower immunoreactivity (IR) than the 2.4 CHX-A″ conjugate. These differences were reflected in the biodistribution of the ¹¹¹In label. The ¹¹¹In-labeled MORAb-009 conjugated with 2.4 CHX-A″ produced higher tumor uptake and lower liver and spleen uptakes than the 5.5 CHX-A″ conjugate. The biodistribution studies also revealed that the tumor uptake was significantly affected by the injected MORAb-009 dose and tumor size. The 30-μg dose produced higher tumor uptake than the 0.2- and 2-μg doses, whereas the 30-μg dose produced lower liver and spleen uptakes than the 0.2-μg dose.

Conclusion

This study demonstrates that the number of chelate conjugation and the injected dose are two important parameters to achieve high tumor and low non-target organ uptake of ¹¹¹In-labeled MORAb-009. This study also suggests that the injected dose of mAb could be individualized based on the tumor size or the blood level of shed antigen in a patient to achieve the ideal tumor-to-organ radioactivity ratios.     

Comparison of ultrasonography and computed tomography for diagnosing diffuse thyroid disease: a multicenter study

Purpose

To compare the diagnostic performance of ultrasonography (US) and computed tomography (CT) for diagnosing incidentally detected diffuse thyroid disease (DTD) in patients who underwent thyroid surgery using multicenter data.

Methods

Between July and December 2016, a total of 177 patients who underwent preoperative thyroid US and neck CT, and subsequent thyroid surgery at 4 participating institutions, were reviewed. US and CT images in each case were retrospectively reviewed by a radiologist at each institution, and classified into one of the following four categories based on US and CT features: no DTD; indeterminate; suspicious for DTD; and DTD. The diagnostic accuracy of US and CT were calculated at each institution by comparison with histopathological results.

Results

Respective US and CT classifications in the 177 patients were no DTD in 75 and 71, indeterminate in 46 and 34, suspicious for DTD in 28 and 31, and DTD in 28 and 41. Among the histopathological results, 113 patients had normal thyroid parenchyma, 23 had Hashimoto thyroiditis, 36 had non-Hashimoto lymphocytic thyroiditis, and 5 had diffuse hyperplasia. The presence of?≥?2 US and CT features of DTD, which was classified as suspicious for DTD or DTD, had the largest area under the receiver operating characteristic curve (0.866 and 0.893, respectively), with sensitivity and specificity of 71.9 and 91.2% in US, and 84.4 and 84.1% in CT, respectively. However, there was no statistically significant difference between readers’ experience and their diagnostic performance.

Conclusion

US and CT imaging may be helpful for detecting incidental DTD.

     

Level of evidence and authorship trends of clinical studies in knee surgery,sports traumatology,arthroscopy, 1995–2015

Purpose

There is increasing emphasis on publication quality and internationalization of author groups in orthopaedic literature. The purpose of this review was to evaluate the type of studies and the level of evidence (LOE) published in knee surgery, sports traumatology, arthroscopy (KSSTA) from 1995 to 2015. The secondary aim was to analyze trends in authorship characteristics in KSSTA.

Methods

Two reviewers reviewed the table of contents of KSSTA and identified original papers from 1995, 2000, 2005, 2010, and 2015. The reviewers graded LOE from Levels I to IV using guidelines from the University of Oxford’s Centre for Evidence-Based Medicine. For each article, the total number of authors and country of author group were also analyzed.

Results

A total of 880 papers were analyzed. The proportions in LOE have stayed consistent throughout the study period (n.s.). There has been a significant increase in the number of published articles and the number of Level I and II studies (P?<?0.01). Therapeutic articles were the most common type. The mean number of authors per KSSTA article significantly increased from 3.9 to 5.7 over the 20-year period (P?<?0.01). The number of represented countries increased yearly and academic institutions from 40 different nationalities published articles in the Journal. Of the examined years, the percent of articles with international collaboration was 17.6%.

Conclusion

The proportion of LOE I and II articles published in KSSTA remains consistently high. Therapeutic studies are the most frequently published articles. There is an increase in international groups publishing in KSSTA.

Level of evidence

IV.