Jan Hein T.M. van Waesberghe

Early Detection of Local RFA Site Recurrence Using Total Liver Volume Perfusion CT: Initial Experience

RATIONALE AND OBJECTIVES The aim of this study was to prospectively evaluate the feasibility of a novel total liver volume perfusion computed tomographic technique in demonstrating treatment-site recurrence of liver metastases after radiofrequency ablation (RFA). MATERIALS AND METHODS Eleven patients considered to be at increased risk for local RFA-site tumor recurrence underwent both positron emission tomography (PET) and perfusion computed tomography (CTP): a 12-phase scan of the entire liver acquired before and 11 times after contrast injection. After coregistration, blood flow maps were created using the maximum slope method. RESULTS In all cases, the CTP-derived blood flow maps fully paralleled the PET images in showing either the absence (nine of 13 lesions) or presence (four of 13 lesions) of local RFA-site recurrence. Marginal lesions with high hepatic arterial perfusion (>50 mL/min/100 g) and low portal venous perfusion (<10 mL/min/100 g) represented recurring vital tumor tissue (P < .05). CONCLUSION Total liver volume CTP seems feasible for the detection and localization of treatment-site recurrence after RFA.

Transcatheter CT Arterial Portography and CT Hepatic Arteriography for Liver Tumor Visualization during Percutaneous Ablation

PURPOSE To evaluate the feasibility of combining transcatheter computed tomography (CT) arterial portography or transcatheter CT hepatic arteriography with percutaneous liver ablation for optimized and repeated tumor exposure. MATERIALS AND METHODS Study participants were 20 patients (13 men and 7 women; mean age, 59.4 y; range, 40-76 y) with unresectable liver-only malignancies--14 with colorectal liver metastases (29 lesions), 5 with hepatocellular carcinoma (7 lesions), and 1 with intrahepatic cholangiocarcinoma (2 lesions)--that were obscure on nonenhanced CT. A catheter was placed within the superior mesenteric artery (CT arterial portography) or in the hepatic artery (CT hepatic arteriography). CT arterial portography or CT hepatic arteriography was repeatedly performed after injecting 30-60 mL 1:2 diluted contrast material to plan, guide, and evaluate ablation. The operator confidence levels and the liver-to-lesion attenuation differences were assessed as well as needle-to-target mismatch distance, technical success, and technique effectiveness after 3 months. RESULTS Technical success rate was 100%; there were no major complications. Compared with conventional unenhanced CT, operator confidence increased significantly for CT arterial portography or CT hepatic arteriography cases (P < .001). The liver-to-lesion attenuation differences between unenhanced CT, contrast-enhanced CT, and CT arterial portography or CT hepatic arteriography were statistically significant (mean attenuation difference, 5 HU vs 28 HU vs 70 HU; P < .001). Mean needle-to-target mismatch distance was 2.4 mm ± 1.2 (range, 0-12.0 mm). Primary technique effectiveness at 3 months was 87% (33 of 38 lesions). CONCLUSIONS In patients with technically unresectable liver-only malignancies, single-session CT arterial portography-guided or CT hepatic arteriography-guided percutaneous tumor ablation enables repeated contrast-enhanced imaging and real-time contrast-enhanced CT fluoroscopy and improves lesion conspicuity.

Enteroscopy and its Relationship to Radiological Small Bowel Imaging

The field of radiological small bowel imaging is changing rapidly, as is small bowel enteroscopy. New techniques allow the depiction of intraluminal, mural, and extraintestinal features of various small bowel disorders, such as Crohn disease, small bowel polyposis syndromes, small intestinal malignancies, and celiac disease. For patients requiring repeated small bowel imaging, modalities that do not use ionizing radiation, such as ultrasound or magnetic resonance imaging, should be considered.

Perfusion Ct and Us of Colorectal Cancer Liver Metastases: A Correlative Study of Two Dynamic Imaging Modalities

The purpose of this study was to evaluate the correlation between dynamic-contrast-enhanced computed tomography (DCE-CT) and first-pass dynamic-contrast-enhanced ultrasound (DCE-US) of normal appearing liver parenchyma and of colorectal cancer liver metastases. Thirty patients with hepatic metastases from colorectal cancer underwent DCE-CT and DCE-US. To obtain DCE-US reproducibility measurements, double contrast-passages (2 × 2.4 mL SonoVue intravenous) were acquired. From several DCE-US-derived perfusion indices, the slope-value scored best with a reproducibility concordance correlation coefficient ranging from 0.75-0.93 and overall highest correlation to DCE-CT-derived variables (r = 0.52 to 0.73). The DCE-US-based tumor-to-liver perfusion gradient also showed a low test-retest variability and moderately correlated to DCE-CT (concordance correlation coefficient 0.87-0.92; r = 0.57 to 0.59). To conclude, DCE-US-based slope-value and tumor-to-liver perfusion gradient correlate best with DCE-CT perfusion values. However, both techniques cannot be used interchangeably. DCE-US should be restricted for studies in which a considerable change in perfusion is expected and for patients with a relatively high tumor blood flow at baseline.

A de novo FLCN mutation in a patient with spontaneous pneumothorax and renal cancer; a clinical and molecular evaluation

Birt–Hogg–Dubé syndrome (BHD) is an autosomal dominant condition due to germline FLCN (folliculin) mutations, characterized by skin fibrofolliculomas, lung cysts, pneumothorax and renal cancer. We identified a de novoFLCN mutation, c.499C>T (p.Gln167X), in a patient who presented with spontaneous pneumothorax. Subsequently, typical skin features and asymptomatic renal cancer were diagnosed. Probably, de novo FLCN mutations are rare. However, they may be under-diagnosed if BHD is not considered in sporadic patients who present with one or more of the syndromic features. Genetic and immunohistochemical analysis of the renal tumour indicated features compatible with a tumour suppressor role of FLCN. The finding that mutant FLCN was expressed in the tumour might indicate residual functionality of mutant FLCN, a notion which will be explored in future studies.

Postpartum monitoring of retained placenta.Two cases of abnormally adherent placenta

To save fertility, hysterectomy may be avoided with abnormal placental adherence by leaving the placenta in situ. Several reports support this strategy, but no reports are available on optimal follow‐up strategies. We present two women with conservative treatment of placenta accreta and describe the prospective monitoring of the clinical course, placental regression, and recovery of the uterine anatomy using serial sonography, hysteroscopy and magnetic resonance imaging. There was no postpartum hemorrhage. Menstrual cyclicity resumed within 18 weeks. The human chorionic gonadotropin serum levels normalized within 10 weeks, whereas regression of placenta tissue was slow and continued up to nine months after delivery. In both cases placental remnants persisted; in one woman they were removed and uterine anatomy restored. She had a subsequent uneventful pregnancy afterwards. The presented systematic follow‐up provides tools to monitor and treat other women in similar ways.

Post-Colonoscopy Massive Air Leakage With Full Body Involvement: An Impressive Complication With Uneventful Recovery

Post-Colonoscopy Massive Air Leakage With Full Body Involvement: An Impressive Complication With Uneventful Recovery

Splenic volume differentiates complicated and non-complicated celiac disease

Background Studies in small groups of patients indicated that splenic volume (SV) may be decreased in patients with celiac disease (CD), refractory CD (RCD) type II and enteropathy-associated T-cell lymphoma (EATL). Objective The objective of this article is to evaluate SV in a large cohort of uncomplicated CD, RCD II and EATL patients and healthy controls. Methods The retrospective cohort consisted of 77 uncomplicated CD (of whom 39 in remission), 29 RCD II, 24 EATL and 12 patients with both RCD II and EATL. The control group included 149 healthy living kidney donors. SV was determined on computed tomography. Results The median SV in the uncomplicated CD group was significantly larger than in controls (202 cm3 (interquartile range (IQR): 154–275) versus 183 cm3 (IQR: 140–232), p = 0.02). After correction for body surface area, age and gender, the ratio of SV in uncomplicated CD versus controls was 1.28 (95% confidence interval: 1.20–1.36; p < 0.001). The median SV in RCD II patients (118 cm3 (IQR 83–181)) was smaller than the median SV in the control group (p < 0.001). Conclusion This study demonstrates large inter-individual variation in SV. SV is enlarged in uncomplicated CD. The small SV in RCD II may be of clinical relevance considering the immune-compromised status of these patients.

Iron Deficiency After Non–Small Cell Lung Cancer

Question: A 57-yearold woman was referred for analysis of iron-deficiency anemia. Five months earlier she had underwent right lower lobectomy for stage 1a non–small cell lung cancer. She did not experience melena or rectal blood loss, nor were there any other abdominal symptoms. Except for a thoracotomy scar, physical examination was unremarkable. Her laboratory studies showed an hemoglobin of 10.8 g/dL. Mean corpuscular volume was 71 fL and serum ferritin was 11 ng/mL. Esophagogastroduodenoscopy howed no abnormalities, whereas ileocolonoscopy revealed mild diverticulosis of the sigmoid, without signs of inflammation. To nvestigate a possible bleeding cause in the small intestine, video capsule endoscopy was performed. The complete small intestine as visualized, but no abnormalities were found. Because of a persisting suspicion of small intestinal bleeding, magnetic resonance enteroclysis was performed. This revealed a .5-cm mass in the proximal ileum (Figure A, arrow). Per-oral double-balloon endoscopy was performed, which located a round essile lesion approximately 3 m from Treitz’s ligament (Figure B). Biopsy specimens were obtained and the proximity of the lesion as marked with submucosal Indian ink. What is the diagnosis? See the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Combination of a six microRNA expression profile with four clinicopathological factors for response prediction of systemic treatment in patients with advanced colorectal cancer

Background First line chemotherapy is effective in 75 to 80% of patients with metastatic colorectal cancer (mCRC). We studied whether microRNA (miR) expression profiles can predict treatment outcome for first line fluoropyrimidine containing systemic therapy in patients with mCRC. Methods MiR expression levels were determined by next generation sequencing from snap frozen tumor samples of 88 patients with mCRC. Predictive miRs were selected with penalized logistic regression and posterior forward selection. The prediction co-efficients of the miRs were re-estimated and validated by real-time quantitative PCR in an independent cohort of 81 patients with mCRC. Results Expression levels of miR-17-5p, miR-20a-5p, miR-30a-5p, miR-92a-3p, miR-92b-3p and miR-98-5p in combination with age, tumor differentiation, adjuvant therapy and type of systemic treatment, were predictive for clinical benefit in the training cohort with an AUC of 0.78. In the validation cohort the addition of the six miR signature to the four clinicopathological factors demonstrated a significant increased AUC for predicting treatment response versus those with stable disease (SD) from 0.79 to 0.90. The increase for predicting treatment response versus progressive disease (PD) and for patients with SD versus those with PD was not significant. in the validation cohort. MiR-17-5p, miR-20a-5p and miR-92a-3p were significantly upregulated in patients with treatment response in both the training and validation cohorts. Conclusion A six miR expression signature was identified that predicted treatment response to fluoropyrimidine containing first line systemic treatment in patients with mCRC when combined with four clinicopathological factors. Independent validation demonstrated added predictive value of this miR-signature for predicting treatment response versus SD. However, added predicted value for separating patients with PD could not be validated. The clinical relevance of the identified miRs for predicting treatment response has to be further explored.