Kei Takase

MRI of Cardiac Sarcoidosis: Basal and Subepicardial Localization of Myocardial Lesions and Their Effect on Left Ventricular Function

OBJECTIVE The objective of our study was to use MRI to analyze the topographic localization of myocardial lesions and their relationship to plasma brain natriuretic peptide (BNP) levels and several cardiac function parameters in patients with cardiac sarcoidosis. MATERIALS AND METHODS Delayed contrast-enhanced MRI was performed in 40 patients with sarcoidosis (11 cardiac, 29 extracardiac cases). Using a 29-segment model of the left ventricle (LV), the extent of myocardial hyperenhancement was visually scored (0 = no hyperenhancement, 1 = 1-25%, 2 = 26-50%, 3 = 51-75%, 4 = 76-100% hyperenhancement) and was compared with plasma BNP level and several parameters of cardiac function. RESULTS Ten of the 11 patients with cardiac sarcoidosis showed myocardial hyperenhancement, whereas none of the 29 patients without cardiac sarcoidosis did. In patients with cardiac sarcoidosis, hyperenhancement was significantly more extensive in basal short axis slices than in apical short axis slices (p < 0.0005). Myocardial hyperenhancement was significantly more frequent in subepicardial layers than in subendocardial layers. The global extent of myocardial hyperenhancement was significantly correlated with plasma BNP levels and the LV end-diastolic volume index and was negatively correlated with the LV ejection fraction. CONCLUSION In patients with cardiac sarcoidosis, myocardial lesions detected on delayed contrast-enhanced MRI were predominantly localized in the basal and subepicardial myocardium. The extent of myocardial lesions may be related to LV dysfunction and plasma BNP level in patients with cardiac sarcoidosis.

Localization of Aldosterone-Producing Adrenocortical Adenomas: Significance of Adrenal Venous Sampling

Accurate localization of aldosterone-producing adenoma (APA) is essential for the treatment of primary aldosteronism (PA). In order to confirm the clinical usefulness of adrenal venous sampling (AVS), we retrospectively studied 87 cases of PA in whom AVS was conducted. We collected right and left adrenal venous effluents simultaneously before and after adrenocorticotropic hormone (ACTH) stimulation for measurements of aldosterone concentration (A) and cortisol concentration (C). Based on AVS results, we judged 66 cases as having unilateral aldosterone hypersecretion and the remaining 21 cases as having no apparent laterality. Of the above 66 subjects, 61 underwent laparoscopic removal of the adrenal gland through a retroperitoneal approach. The presence of APA was histopathologically confirmed, and blood pressure decreased significantly with normalization of plasma aldosterone concentration (PAC) in all cases. The receiver operator characteristics (ROC) curve analysis between the operated and no–apparent-laterality groups revealed that the ratio of A/C on the higher side to A/C on the lower side (A/C ratio) after ACTH stimulation is a useful index, with a cutoff value of 2.6, a sensitivity of 0.98 and a specificity of 1.0. The ROC curve analysis between the APA side and contralateral side within the operated patients revealed that the cutoff value of A was 1,340 ng/dL, with a sensitivity of 0.92 and a specificity of 1.00. Our results indicate the usefulness of simultaneous AVS and ACTH stimulation for localizing APA.

Electrocardiographic Characteristics of the Variants of Idiopathic Left Ventricular Outflow Tract Ventricular Tachyarrhythmias

Background: Despite similar QRS morphology, idiopathic repetitive monomorphic ventricular tachyarrhythmias (VTs) of left ventricular outflow tract (LVOT) are known to have the variants of different adjacent origins, including the aorto‐mitral continuity (AMC), anterior site around the mitral annulus (MA), aortic sinus cusps (ASC), and epicardium. However, the electrocardiographic characteristics of those variants previously have not been evaluated fully.

Luminal-type breast cancer: correlation of apparent diffusion coefficients with the Ki-67 labeling index.

PURPOSE To evaluate the correlation between apparent diffusion coefficient ( ADC apparent diffusion coefficient ) values and the Ki-67 labeling index for luminal-type (estrogen receptor-positive) breast cancer not otherwise specified ( NOS not otherwise specified ) diagnosed by means of biopsy. MATERIALS AND METHODS The institutional review board approved this retrospective study, and the requirement for informed consent was waived. Between December 2009 and December 2012, 86 patients with 86 lesions with luminal-type invasive breast cancer NOS not otherwise specified underwent magnetic resonance imaging, including dynamic contrast material-enhanced imaging and diffusion-weighted imaging with b values of 0 and 1000 sec/mm(2). Conventional measurement of the minimum and mean ADC apparent diffusion coefficient s by placing regions of interest and histogram analysis of pixel-based ADC apparent diffusion coefficient data of the entire tumor were performed by two observers independently and correlated with the Ki-67 labeling index of surgical specimens. RESULTS For the interobserver reliability, interclass correlation coefficients for all parameters with the exception of the minimum ADC apparent diffusion coefficient exceeded 0.8, indicating almost perfect agreement. The minimum ADC apparent diffusion coefficient and mean ADC apparent diffusion coefficient and the 25th, 50th, and 75th percentiles of the histograms showed negative correlations with the Ki-67 labeling index (r = -0.49, -0.55, -0.54, -0.53, and -0.48, respectively). Receiver operating characteristic curve analysis for the differential diagnosis between the high-proliferation (Ki-67 ≥ 14; n = 44) and low-proliferation (Ki-67 < 14; n = 42) groups revealed that the most effective threshold for the mean ADC apparent diffusion coefficient was lower than 1097 × 10(-6) mm(2)/sec, with sensitivity and specificity of 82% and 71%, respectively. The area under the receiver operating characteristic curve (AUC) was 0.81 for the mean ADC apparent diffusion coefficient . There were no significant differences in the AUC among the parameters. CONCLUSION Considering convenience for routine practice, the authors suggest that the mean ADC apparent diffusion coefficient of the conventional method would be practical to use for estimating the Ki-67 labeling index.

18-Oxocortisol Measurement in Adrenal Vein Sampling as a Biomarker for Subclassifying Primary Aldosteronism

CONTEXT 18-Oxocortisol (18-oxoF) is a derivative of cortisol (F) that is produced by aldosterone synthase (CYP11B2). The potential for this steroid as a biomarker for differentiating patients with aldosterone-producing adenoma (APA) from those with idiopathic hyperaldosteronism (IHA) has not been examined. OBJECTIVES We measured 18-oxoF, aldosterone, and F in plasma from adrenal vein sampling (AVS) of patients with primary aldosteronism. We compared 18-oxoF levels and 18-oxoF/F ratios for their potential to differentiate APA from IHA. DESIGN, SETTING, AND SUBJECTS This study measured 18-oxoF, F, and aldosterone in AVS obtained from patients with unilateral APA (14 cases) or bilateral IHA (seven cases, 14 samples total) using liquid chromatography-tandem mass spectrometry and RIA analyses. RESULTS The levels of 18-oxoF and the ratios of 18-oxoF/F, before and after ACTH stimulation, were significantly higher in blood-draining APA than in those from the contralateral adrenal glands and from adrenal glands with IHA. CONCLUSIONS The 18-oxoF levels and ratios of 18-oxoF/F in AVS samples can be a clinically useful biomarker for differentiating APA from IHA and for determining the localization or lateralization of APA in patients with primary aldosteronism.

Evaluation of the relationship between physiological FDG uptake in the heart and age, blood glucose level, fasting period, and hospitalization

ObjectivePositron emission tomography (PET) with fluorodeoxyglucose (FDG) is widely used for evaluation of cancer and ischemic heart disease. Recently, increased myocardial FDG uptake has been reported to be related to some types of heart disease, such as sarcoidosis. However, the physiological increased FDG uptake in the heart often mimics the abnormal high uptake in these cases. In this study, we investigated the relationships between myocardial uptake and age, blood glucose level, fasting period, and hospitalization status (inpatient vs. outpatient).MethodsA total of 159 non-diabetic patients were enrolled in the present study. Patients were imaged on a PET/CT scanner, and a three-dimensional region of interest (ROI) was drawn on the fused PET/CT image to measure the maximum standardized uptake value (SUVmax) of the whole left ventricle.Results: No significant relationships were observed between myocardial uptake and age or fasting period. Blood glucose level showed a significant relationship (p = 0.025) with myocardial uptake, but the R-square was extremely small (r2 = 0.03). With an SUVmax threshold of 3.0, there was no significant difference between inpatients and outpatients. However, outpatients showed a significantly higher frequency of myocardial uptake over SUVmax of 5.0 (x2 test: p = 0.046).ConclusionIt is difficult to predict the degree of physiological uptake in the heart from data regarding age, fasting period, or blood glucose level. Outpatients tend to show higher myocardial uptake than inpatients, which may make it difficult to detect abnormally increased uptake in the heart. A long fasting period, such as overnight fasting, is an inadequate means to reduce the physiological uptake of FDG in the heart.

Intraductal papillary mucininous neoplasm of the bile ducts: multimodality assessment with pathologic correlation

Mucin-producing intraductal papillary neoplasm (adenocarcinoma/adenoma) in the bile duct is becoming recognized as a specific type of neoplasm. Since, it bears a striking similarity to intraductal papillary mucinous neoplasms of the pancreas with regard to its histopathologic features, the term “intraductal papillary mucinous neoplasms of the bile duct” (IPMN-B) is frequently used, although no definite terminology or definition has been decided by World Health Organization. This neoplasm lacks ovarian-like stroma and communicates with the bile ducts, unlike biliary mucinous cystic neoplasm (MCN). On the other hand, malignant IPMN-B is categorized as an intraductal-growth type of intrahepatic cholangiocarcinoma (ICC). In comparison to other types of ICC, such as the mass-forming type and periductal-infiltrating type that have poor resectability and an unfavorable prognosis, malignant IPMN-B can be resected and demonstrates a more favorable prognosis. Meanwhile, unlike biliary MCN that is usually confined in a closed cyst, IPMN-B can spread along the mucosal surface of the bile ducts, and it should be widely resected. Therefore, multimodality assessment is needed to ensure the correct diagnosis of IPMN-B. We herein review the imaging findings of IPMN-B with pathologic correlation.

Isoform-Specific Monoclonal Antibodies Against 3β-Hydroxysteroid Dehydrogenase/Isomerase Family Provide Markers for Subclassification of Human Primary Aldosteronism

CONTEXT Therapeutic management of primary aldosteronism requires accurate differentiation between aldosterone-producing adenoma (APA) and idiopathic hyperaldosteronism (IHA). However, little is known about the molecular features that delineate the difference between APA and IHA. Two different isoforms of 3β-hydroxysteroid dehydrogenase (HSD3B1 and HSD3B2) are thought to be expressed in the human adrenal gland, but the lack of isoform-specific antibody has so far hampered mapping of these isoforms in APA and IHA. OBJECTIVES The aim of our study is to develop and characterize isoform-specific monoclonal antibodies against HSD3B1 and HSD3B2. Using these antibodies, we determined for the first time the immunolocalization of HSD3B1 and HSD3B2 in normal human adrenal cortex as well as in adrenal specimens from APA and IHA. RESULTS Immunohistochemical analysis with isoform-specific antibodies revealed zone-specific expression of HSD3B1 and HSD3B2 in the adrenal cortex. HSD3B1 immunoreactivities were essentially confined to the zona glomerulosa (ZG), in which aldosterone is produced. In contrast, HSD3B2 was not confined to the ZG but was found across the zona fasciculata, which is where cortisol is produced. Moreover, immunohistopathological analysis of primary aldosteronism revealed a previously uncharacterized difference between APA and IHA. Notably, hyperplasia of ZG seen for IHA was accompanied by a robust expression of ZG isoform HSD3B1. In contrast, tumor cells in APA were not immunopositive to HSD3B1. Rather, a strong and dominant expression of HSD3B2 characterized APA. Moreover, perhaps due to compensatory responses to excess aldosterone, APA had an adjacent ZG whose immunoreactivities to HSD3B1 and HSD3B2 were profoundly reduced. CONCLUSIONS Isoform-specific monoclonal antibodies against HSD3B1 and HSD3B2 may be of great value for immunohistochemical differentiation between APA and IHA.

Bronchial Artery Anatomy: Preoperative 3D Simulation with Multidetector CT

PURPOSE To preoperatively evaluate anatomic variations of the bronchial arteries by obtaining three-dimensional (3D) simulations with multidetector computed tomography (CT). MATERIALS AND METHODS This study was approved by the institutional review board, and written informed consent was obtained from all participants. Seventy-three consecutive patients with esophageal cancer underwent dynamic multidetector CT. The data were used to generate 3D simulations of the thoracic cavity. These images were then used to evaluate anatomic variations of the bilateral bronchial arteries and the mediastinal course in relation to the esophagus and trachea-bronchi. The preoperative CT findings were correlated with the thoracoscopic findings. RESULTS CT depicted 118 right bronchial and 105 left bronchial arteries. The right bronchial arteries arose from the intercostal-bronchial trunk (IBT), thoracic aorta, common trunk of both bronchial arteries (CTB), and right subclavian artery in 61, 15, 38, and four cases, respectively, whereas the left bronchial arteries arose from the thoracic aorta, IBT, and CTB in 63, four, and 38 cases, respectively. The right bronchial arteries followed preferential courses through the mediastinum, depending on the parent artery: All 61 right bronchial arteries that arose from the IBT ran along the right side of the esophagus, dorsal to the trachea-main bronchi, whereas the majority of direct-origin and CTB-type right bronchial arteries and all left bronchial arteries ran along the left side of the esophagus. During right thoracoscopy, all bronchial arteries coursing along the right side of the esophagus were identified, whereas those coursing along the left side of the esophagus were frequently out of intraoperative view. Six small right bronchial arteries that were not detected at CT were discovered during surgery. CONCLUSION Three-dimensional simulation with multidetector CT yields precise preoperative information regarding the anatomy of the bronchial arteries and their variants.

Predictors of decreasing glomerular filtration rate and prevalence of chronic kidney disease after treatment of primary aldosteronism: renal outcome of 213 cases.

CONTEXT In primary aldosteronism (PA), glomerular hyperfiltration due to excessive aldosterone is considered to underestimate actual renal damage. OBJECTIVE Our objectives were to determine the prevalence of chronic kidney disease (CKD) in PA and identify the predictors of decreasing estimated glomerular filtration rate (eGFR) after treatment. DESIGN AND SETTING This was a 12-month prospective study of patients with PA treated at Tohoku University Hospital. PATIENTS AND INTERVENTIONS All patients were treated according to the results of adrenal venous sampling; 102 patients with aldosterone-producing adenoma underwent adrenalectomy, and 111 with bilateral hyperaldosteronism were treated with mineralocorticoid receptor antagonists. MAIN OUTCOME MEASURES Electrolytes, blood pressure, and indicators of renal function were determined at 1 and 12 months after intervention. RESULTS Blood pressure, urinary albumin excretion (UAE), and eGFR, which significantly decreased at 1 month after treatment of PA, did not further decrease at 12 months. Prevalence of CKD, which was 15.7% in aldosterone-producing adenoma and 8.1% in bilateral hyperaldosteronism at the first visit, increased to 37.1% and 28.3%, respectively, at the end of study (P < .0001). Multivariate regression analysis revealed that higher UAE and lower serum potassium levels were found to be independent predictors of decreasing eGFR after intervention. CONCLUSIONS This large cohort study shows that the prevalence of CKD in PA was increased after treatment and that higher UAE and lower serum potassium levels at the first visit were predictors of decreasing eGFR after treatment of PA. To prevent a large decrease of eGFR after intervention, PA patients should be diagnosed before evolution to severe albuminuria and hypokalemia.