Ehiichi Kohda

Pancreatoblastoma: Three original cases and review of the literature:

Purpose: To describe the characteristics of pancreatoblastoma. Material and Methods: We studied 3 cases of pancretoblastoma and reviewed another 59 cases. Parameters analyzed were tumor site, hemorrhage, capsule formation, necrosis, vascularity, production of alpha-fetoprotein (AFP), cystic changes and calcification. Results: The diagnostic findings were as follows: pancreatic head origin (24/54, 44%), pancreatic body and tail origin (30/54, 56%), hemorrhage (16/17, 94%), capsule formation (24/26, 92%), necrosis (28/31, 90%), hypervascularity (10/14, 71%), production of AFP (19/28, 68%), cystic changes (11/16, 69%), and calcification (10/21, 48%). All neonatal cases demonstrated cystic changes. Three of them were patients with Beckwith-Wiedmann syndrome. The incidence of capsule formation and calcification was not related to the origin of the tumor. Conclusion: The most common features of pancreatoblastoma are hemorrhage, capsule formation and necrosis.

Bronchopulmonary arterial anastomosis at the precapillary level in human lung. Visualization using CT angiography compared with microangiography of autopsied lung.

Purpose: To investigate the interrelationships between the bronchial and pulmonary circulations including the existence of precapillary bronchopulmonary arterial anastomoses. Material and Methods: CT of bronchial arteriography (BAG-CT) was performed in 10 patients and BAG-CT during a pulmonary artery block test (PA-block) in 5 patients with lung cancer. Bronchial and pulmonary circulations were evaluated in 5 autopsied normal lungs by injecting silicone rubber with different colors into the bronchial and pulmonary arteries. Results: BAG-CT correlated well with the findings at silicone rubber injection into lung autopsy samples. BAG-CT demonstrated inflow of contrast medium into the pulmonary artery during PA-block in all cases, while no inflow was observed before and following reversal of PA-block. Mixed silicone rubber was observed in the lobar to subsubsegmental bronchial arteries in all cases and in the subsubsegmental pulmonary artery in one case. Conclusion: Precapillary bronchopulmonary arterial anastomoses may exist at the level of the lobar bronchi to the periphery. If either the pulmonary or bronchial circulation is disturbed, flow occurs inside the anastomoses to supplement the other flow, especially flow from the bronchial to the pulmonary arteries via the anastomoses, which occurs within 30 min.

Swallowing Dysfunction and Aspiration in Neonates and Infants

In children, swallowing dysfunction and aspiration are common causes of recurrent pneumonia and can be fatal. The underlying mechanism is still unknown. In this study, we evaluated the swallowing function in 72 neonates and infants by fluoroscopy and followed the course of 39 patients for more than one year. The results of all the examinations were recorded on videotape or a digital imaging system. All 10 patients with neurologic disorder presented cricopharyngeal dysfunction. Of the 12 patients with near miss sudden infant death syndrome, 10 showed nasopharyngeal reflux, and 5 demonstrated cricopharyngeal dysfunction. In the 50 patients without neurologic disorder, 29 revealed cricopharyngeal dysfunction. Laryngeal elevation was not seen in 75%. Three of these 29 patients had no other abnormality. All patients without neurologic disorder recovered well. Seven patients demonstrated prolonged aspiration. Four of them had neurologic disorder, and the rest had near miss sudden infant death syndrome. Fluoroscopic examination showed two types of aspiration: one was caused not only by pharyngeal but also by lingual muscles. It was not associated with any neurologic disorders and the symptoms were transient. The other was caused by cricopharyngeal dysfunction and most of these patients had neurologic diseases and prolonged symptoms.

Pulmonary hilar lymph nodes in lung cancer: assessment with 3D-dynamic contrast-enhanced MR imaging.

PURPOSE We performed 3D-dynamic MRI on patients with primary lung cancer to identify its usefulness for detecting hilar adenopathy shown at surgery. METHODS AND MATERIALS 30 consecutive patients with peripheral lung cancer underwent preoperative 3D-dynamic Gd-DTPA-enhanced MRI. Two thoracic radiologists blinded to histopathologic findings reviewed those studies independently for hilar adenopathy visualization. The results were correlated with surgical and histopathologic findings. Interreader agreement for the detection of hilar adenopathy was assessed by means of the kappa statistic. RESULTS Dynamic MRI demonstrated hilar adenopathy, with or without metastasis revealed at surgery, in all of 15 patients. Adenopathy without metastasis was shown in four patients. Dynamic MRI also revealed metastatic adenopathy in 11 of 12 patients with pathologically proven metastasis. There was only one case with lymph node metastasis that did not have adenopathy either on MRI or even at surgery. The diagnostic accuracy of dynamic MRI for adenopathy with or without metastases revealed at surgery were as follows; sensitivity, 100%; specificity, 100%; positive predictive value, 100%; and negative predictive value, 100%, respectively. The diagnostic accuracy of dynamic MRI for hilar lymph nodes metastasis were as follows; sensitivity, 92%; specificity, 78%; positive predictive value, 73%; and negative predictive value, 93%. Interreader agreement was substantial (kappa=0.73) for detection of hilar adenopathy. CONCLUSION Hilar adenopathy on 3D-dynamic MRI correlated well with that of surgical finding on patients with primary lung cancer. It may have the potential to make an accurate preoperative evaluation of hilar lymph node metastasis from lung cancer.

Inter-hospital PACS designed for teleradiology and teleconference using a secured high-speed network

We developed a tele-radiology and tele-conference system between our related hospitals. This system consisted of the image database, the WWW server, WWW browsers, high resolution CRT displays, the videoconference system and an asynchronous transfer mode (ATM) network. In advance X-ray images were stored into the Image Save And Carry magneto- optical (MO) disks, then images on the MO were transferred to the image database. The image database was created from MO disks. Total amount of images reached 100 GB and the number of the image was 65,000. The ATM network connected the hospitals each other. The ATM network device provided the permanent virtual circuit function. The transmission speed was from 6Mbit/second to 155 Mbit/second. The client station consisted of the WWW browser and the super high definition CRT display which had the 2k X 2k full color frame memory and 54 X 54 cm square display area. The result of the query was transformed to a hypertext markup language. Then a browser on a client machine displayed the result. The server could retrieve some images in about ten seconds and transmit an image from a server to a client in 2-10 seconds that depend on the network speed. At the tele- radiology, both terminals could display same image and physicians could talk each other by the videoconference system. We solved the security problems by the PVC methods and the on time password device. The ATM network showed the high transmission performance and good security. Physicians were able to use this system with no special training and this system brought us an effective utilization of the image.

Radial MRI during free breathing in contrast-enhanced hepatobiliary phase imaging

Background Use of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) for diagnosis of hepatic tumors has been previously reported. Fat-saturated 3D T1-weighted gradient echo sequence (TIGRE) imaging using a breath-hold technique is usually used for dynamic studies and hepatobiliary phase Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI). In cases where the patient has difficulty holding their breath, this scanning method can be difficult. Purpose To investigate the usefulness of a fat-saturated T1-weighted spin-echo (SE) sequence using a radial read-out (radial acquisition regime-SE, RADAR-SE) during free breathing for hepatobiliary phase Gd-EOB-DTPA-enhanced MRI. Material and Methods Images were acquired at 1.5 T. First, a phantom with diluted Gd-EOB-DTPA was scanned using the TIGRE sequence and the RADAR-SE sequence. Contrast ratios of the sequences were compared. Next, the hepatobiliary phase was imaged in 62 patients using the TIGRE sequence with breath-hold and the RADAR-SE during free breathing. Qualitative and quantitative evaluations were compared. Results In the phantom study, RADAR-SE had a higher contrast ratio than TIGRE. In the clinical study, artifacts were more conspicuous in RADAR-SE compared to TIGRE images in the qualitative evaluation. However, RADAR-SE images were equal to or better than TIGRE images in patients who had difficulty holding their breath. The signal intensity ratio of the liver was statistically higher using RADAR-SE than TIGRE. Conclusion RADAR-SE can be useful for hepatobiliary phase Gd-EOB-DTPA-enhanced MRI in patients who have difficulty holding their breath.

Factors associated with delayed gastric emptying in patients with stent placement for malignant gastric outlet obstruction

Background and study aims: Delayed gastric emptying (DGE) is an important factor in determining the clinical outcome in patients with stent placement for malignant gastric outlet obstruction but the factors associated with DGE remain unclear. The aim of this study was to investigate whether clinicopathologic data could be used to identify the factors for DGE in such patients. Patients and methods: A prospective, single-arm, observational clinical study was performed in a referral hospital in Japan. A total of 54 patients with stent placement for malignant gastric outlet obstruction were enrolled. A gastric emptying scintigraphy test was performed 1 week after stent placement. The relationship between DGE and clinicopathologic factors was investigated, and also the relationship between DGE and stent patency time, eating period (when the patient was able to maintain oral intake), and survival time. Results: A total of 38.9 % (21 /54) of patients had DGE. The following were identified as independent predictive factors of DGE: opioid use (odds ratio, 5.32; 95 % confidence interval [95 %CI], 1.07 – 26.41; p = 0.04), chemotherapy before stent placement (odds ratio, 8.03; 95 %CI, 1.85 – 34.95; p = 0.006), and smaller stent diameter (odds ratio, 13.59; 95 %CI, 1.72 – 107.41; p = 0.01). No relationship was found between DGE and the level of oral intake, stent patency time, eating period, and survival time. Conclusions: The factors associated with DGE after stent placement include those associated with the patient’s tumor as well as factors relating to their treatment, including stenting. The clinical and functional results after stent placement appear to be unrelated to the gastric emptying findings.

Pediatric high-flow, cervical spinal, macro-arteriovenous fistula, treated with the endovascular cotton candy glue injection technique

Case reportA 3-year-old boy presented to our hospital with progressive neurological deficits. Spinal magnetic resonance imaging (MRI) revealed a perimedullary macro-arteriovenous fistula (PMAVF) resulting in a large venous pouch within the parenchyma of the lower cervical spinal cord.Transarterial varix embolization of the fistula from the venous side was performed using N-butyl cyanoacrylate with tantalum powder. Postembolization angiography confirmed obliteration of the fistula, and MRI revealed thrombosis and reduction in size of the venous component. The patient’s clinical symptoms were reduced dramatically following the intervention, and no neurological complications occurred due to the treatment. The prognosis of spinal PMAVF depends primarily on the presence of medullar signs and symptoms and on time to treatment. The volume of the venous pouch after the intervention was markedly reduced, and complete clinical recovery was obtained. Urgent endovascular intervention, as seen in this case, is considered first-line therapy and aims to decrease the risk of neurological sequela.

High-flow Neonatal Macrocerebral Arteriovenous Fistulas in Hereditary Hemorrhagic Telangiectasia.

Although some cases of vein of Galen aneurysmal malformation (VGAM) present initial clinical symptoms such as cardiopulmonary disturbance in the neonatal period, pial arteriovenous fistula is very seldom present as a clinical symptom immediately after birth. A neonatal patient, the first-born to his family, presented with tachypnea postpartum. This baby had a family history of hereditary hemorrhagic telangiectasia. A cerebral MR image revealed multiple macrocerebral arteriovenous fistulas (MCAVFs), resulting in a large partially thrombosed venous pouch within the cerebral cortex. Trans-arterial embolizations of the main two fistulas were performed using N-butyl cyanoacrylate (NBCA) with tantalum powder six months after birth. Post-embolization angiography confirmed the obliteration of the fistulas and magnetic resonance imaging (MRI) revealed thrombosis and reduction in size of the venous component. His tachypnea disappeared completely. There were no neurological complications due to the treatment. The prognosis of multiple MCAVFs mainly depends on the presence of medullar signs and symptoms and a delay before treatment. Pure glue endovascular intervention, as used in our case, is considered to be the first therapeutic choice to decrease the risk of neurological consequences.

Revisit image control for pediatric chest radiography

PurposeThe aim of this study was to analyze the fraction defectiveness and efficacy of the patient immobilization device (PID) for pediatric chest radiography.Materials and methodsWe examined 840 plain chest radiographs in six hospitals, including four childrens hospitals and two general hospitals. The mean age of the patients was 1.9 years (range 0–5 years). Two board-qualified pediatric radiologists rated (into three grades, by consensus) the degree of inspiration, rotation, lordosis, scoliosis, and cutoff or coning as well as the quality of the chest radiographs.ResultsThe incidence of “poor” and “very poor” quality examinations was 2/140 and 3/140 in each of two childrens hospitals using PID. The corresponding figures were 9/139 and 17/140 in the two childrens hospitals that did not use PID. The general hospital using PID had 14/140 “poor” and “very poor” examinations. The general hospital that did not use PID had 28/140 “poor” and “very poor” examinations. Thus, statistically better quality chest radiography was obtained with the use of PID (P < 0.001). Likewise, rotation, lordosis, and scoliosis were less frequently diagnosed as present when PID was used (P < 0.001, 0.001, 0.05). Cutoff or coning had no relation to the use of PID (P = 0.13). No significant difference was found between the degree of inspiration and the use of PID (P = 0.56).ConclusionFraction defectiveness in the general hospital that did not use PID was as much as 14 times higher than that of the childrens hospitals that used PID. The patient immobilization device is recommended for hospitals with technologists not specifically trained for pediatric examination.