Sota Oguro

Short-term results of transcatheter arterial embolization for abnormal neovessels in patients with adhesive capsulitis: a pilot study

BACKGROUND Neovessels and accompanying nerves are possible sources of pain. We postulated that transcatheter arterial embolization of abnormal neovessels would relieve pain and symptoms in patients with adhesive capsulitis. METHODS Adhesive capsulitis was treated by transcatheter arterial embolization in 7 patients. Adverse events, changes in visual analog scale scores for night pain and overall shoulder pain, and changes in range of motion and American Shoulder and Elbow Surgeons scores were assessed at 1 week and at 1, 3, and 6 months after the procedure. RESULTS Abnormal neovessels were identified at the rotator interval in all patients. No major or minor adverse events were associated with the procedures. Transcatheter arterial embolization rapidly decreased nighttime pain scores from 67 ± 14 mm to 27 ± 14 mm at 1 week after the procedure, with further improvement at 1 and 6 months (6 ± 8 mm and 2 ± 5 mm, respectively). The American Shoulder and Elbow Surgeons score significantly improved from 17.8 ± 4.5 to 39.8 ± 12.0, 64.3 ± 13.9, and 76.2 ± 4.4 at 1, 3, and 6 months, respectively. CONCLUSION All patients with adhesive capsulitis had abnormal neovessels at the rotator interval. Transcatheter arterial embolization was feasible, relieved unrelenting pain, and restored shoulder function.

Transcatheter Arterial Embolization Using Imipenem/Cilastatin Sodium for Tendinopathy and Enthesopathy Refractory to Nonsurgical Management

PURPOSE To evaluate the feasibility and effects of transcatheter arterial embolization with imipenem/cilastatin sodium (CS) to treat tendinopathy and enthesopathy that are refractory to traditional nonsurgical management. MATERIALS AND METHODS Transcatheter arterial embolization with imipenem/CS as an embolic agent was performed in seven patients (five men; mean age, 51.7 y) with tendinopathy and enthesopathy (patellar tendinopathy, n = 1; rotator cuff tendinopathy, n = 2; plantar fasciitis, n = 1; lateral epicondylitis, n = 1; iliotibial band syndrome, n = 1; and Achilles insertion tendinopathy, n = 1). All patients had unrelenting pain at the site of tendinopathy and enthesopathy before the procedure. Technical success, adverse events, and changes in visual analog scale (VAS) scores were assessed. RESULTS All procedures were technically successful, and no major adverse events developed. Compared with before the procedure, mean VAS scores were significantly decreased at 1 day, 1 week, and 1 and 4 months after the procedure (72.7 mm±9.9 vs 17.4 mm±18.5, 16.0 mm±18.1, 13.7 mm±7.3, and 9.7 mm±6.8, respectively; all P< .001). CONCLUSIONS Transcatheter arterial embolization with imipenem/CS was feasible and effectively relieved unrelenting pain associated with tendinopathy and enthesopathy.

Clinical Outcomes of Transcatheter Arterial Embolization for Adhesive Capsulitis Resistant to Conservative Treatment

PURPOSE To evaluate clinical outcomes of transcatheter arterial embolization (TAE) for adhesive capsulitis resistant to conservative treatments. MATERIALS AND METHODS This study comprised 25 patients (18 women and 7 men; mean age, 53.8 y; range, 39-68 y) with adhesive capsulitis resistant to conservative treatments. TAE was performed, and adverse events (AEs), pain visual analog scale (VAS) score changes, range of motion (ROM), and American Shoulder and Elbow Surgeons (ASES) scores were assessed. RESULTS Abnormal vessels were identified in all patients. No major AEs were associated with TAE. One patient was lost to follow-up. The remaining 24 patients were available for final follow-up (mean, 36.1 months; range, 30-44 months). Of the 24 patients, 16 (67%) experienced quick improvement of nighttime pain (ie, VAS scores decreased > 50% from baseline) within 1 week, and 21 (87%) improved within 1 month. In terms of mean overall pain (ie, pain at its worst), VAS scores significantly decreased at 1, 3, and 6 months after treatment (82 mm before treatment vs 52, 19, and 8 mm after treatment; P < .001). ASES scores significantly improved at 1, 3, and 6 months after treatment (16.1 before treatment vs 41.4, 69.1, and 83.5 after treatment; P < .001). No symptom recurrence or late-onset AEs were observed. Shoulder ROM and function further improved during midterm follow-up. CONCLUSIONS TAE is a possible treatment option for patients with adhesive capsulitis that has failed to improve with conservative treatments.

Giant Cell Tumors of the Bone: Changes in Image Features after Denosumab Administration

Purpose: To assess the clinical importance in the feature change in giant cell tumors of the bone (GCTB) after denosumab treatment, detected by MRI. Methods: In 12 patients, MRI and CT of GCTB obtained before and after the treatment retrospectively compared. The tumor size, the signal intensity (SI) ratio between the solid part of the GCTB and muscle, cystic part size, gadolinium enhancement and apparent diffusion coefficient (ADC) value were measured on MRI. The bone formation in the tumor was observed on CT and X-ray. Results: The mean number of denosumab injections was 19 ± 10. The follow-up period was up to 2 years. One case showed partial remission, while the other 11 cases were stable. A mean SI ratio on T2-weighted image statistically significantly decreased from 3.9 to 1.9 after the treatment. A cystic component in the tumor was observed in five cases before the treatment, and the diameter of the cystic part decreased after the treatment in 80% of cases (4/5). All the tumors showed contrast enhancement on T1-weighted image pre- and post-treatment (11/11). The averaged ADC values were 1.52 × 10−3 mm2/s before and 1.44 × 10−3 mm2/s after the treatment (P = 0.63). Bone formation in the tumor was observed in 58% of cases (7/12). Conclusion: The decrease of SI ratio on T2-weighted image, shrinkage of cystic part and bone formation should be regarded as the effectiveness of denosumab treatment despite of no substantial change in the tumor size.

Quantitative assessment of fatty infiltration and muscle volume of the rotator cuff muscles using 3-dimensional 2-point Dixon magnetic resonance imaging

BACKGROUND In patients with rotator cuff tears, muscle degeneration is known to be a predictor of irreparable tears and poor outcomes after surgical repair. Fatty infiltration and volume of the whole muscles constituting the rotator cuff were quantitatively assessed using 3-dimensional 2-point Dixon magnetic resonance imaging. METHODS Ten shoulders with a partial-thickness tear, 10 shoulders with an isolated supraspinatus tear, and 10 shoulders with a massive tear involving supraspinatus and infraspinatus were compared with 10 control shoulders after matching age and sex. With segmentation of muscle boundaries, the fat fraction value and the volume of the whole rotator cuff muscles were computed. After reliabilities were determined, differences in fat fraction, muscle volume, and fat-free muscle volume were evaluated. RESULTS Intra-rater and inter-rater reliabilities were regarded as excellent for fat fraction and muscle volume. Tendon rupture adversely increased the fat fraction value of the respective rotator cuff muscle (P < .002). In the massive tear group, muscle volume was significantly decreased in the infraspinatus (P = .035) and increased in the teres minor (P = .039). With subtraction of fat volume, a significant decrease of fat-free volume of the supraspinatus muscle became apparent with a massive tear (P = .003). CONCLUSION Three-dimensional measurement could evaluate fatty infiltration and muscular volume with excellent reliabilities. The present study showed that chronic rupture of the tendon adversely increases the fat fraction of the respective muscle and indicates that the residual capacity of the rotator cuff muscles might be overestimated in patients with severe fatty infiltration.

CT during arteriography to visualize the right adrenal vein for adrenal venous sampling

The present report describes 6 cases of adrenal venous sampling (AVS) in patients who underwent computed tomography (CT) during arteriography because cannulation of right adrenal veins was otherwise difficult. CT was performed during arteriography to obtain information on the location and direction of the right adrenal vein. Two right adrenal veins were visualized in 1 case. The right central adrenal vein was not visualized in 1 case owing to an injury from a previous unsuccessful AVS procedure, but the right renal capsular vein was well visualized. CT during arteriography could contribute to a high AVS success rate.

PS 17-01 USEFUL APPLICATION OF COMPUTED TOMOGRAPHY DURING ARTERIOGRAPHY FOR A CASE OF ALDOSTERONE-PRODUCING ADENOMA WITHOUT A SIGN OF OVERPRODUCTION OF ALDOSTERONE IN ADRENAL VENOUS SAMPLING.

Objective: We sometimes experience a case of aldosterone-producing adenoma (APA) without a sign of overproduction of aldosterone in adrenal venous sampling (AVS). One of the reasons is that APA can form ectopic drainage veins besides the authentic adrenal central veins. We tried to utilize computed tomography (CT) during arteriography for identification of such drainage veins in a case of APA. Design and method: A 56-year-old Japanese male was treated for hypertension with amlodipine (5 mg/day) for the past 6 years. In April 2015, primary aldosteronism (PA) was suspected because a laboratory examination showed hypokalemia (2.6 mEq/L). Endocrinological evaluations indicated hyperaldosteronism with high aldosterone renin ratio (ARR): plasma aldosterone concentration (PAC) 272 pg/ml, plasma renin activity (PRA) 0.2 ng/ml/hr and ARR 1360. Abdominal CT suggested APA of 8 mm in diameter at the left adrenal gland. AVS was performed to confirm overproduction of aldosterone from APA; however, the overproduction was not identified in both sides of adrenal central veins, in spite of successful cannulation. We performed CT during arteriography to identify outflow from the adenoma in consideration of ectopic drainage veins. Results: The left renal capsular vein and a small branch to the left renal vein were clearly visualized as drainage veins from the adenoma. AVS was again conducted from these drainage veins and we successfully confirmed overproduction of aldosterone from them. He was diagnosed as left APA and laparoscopic adrenalectomy was performed. After the operation, the blood levels of PAC and PRA became normal and his blood pressure and hypokalemia also normalized. Conclusions: There are several reports that demonstrate ectopic drainage veins from adrenal adenoma (JAMA Surg. 148:378, 2013). Identification of aldosterone overproduction in APA with ectopic drainage veins is not easy for conventional AVS procedure. CT during arteriography is indicated to be useful for identification of ectopic drainage veins in such case of APA.

PS 17-04 SUPER-SELECTIVE ADRENAL VEIN SAMPLING IS USEFUL FOR ALDOSTERONE-PRODUCING ADENOMA UNDIAGNOSABLE BY CONVENTIONAL ADRENAL VEIN SAMPLING: SINGLE-CENTER REVIEW OF UNDIAGNOSABLE CASES

Objective: Although adrenal vein sampling (AVS) is the gold standard for diagnosing subtypes of primary aldosteronism (PA), it is sometimes difficult to make correct diagnosis by conventional AVS in which only adrenal central veins are selected. We recently employed a new approach, super-selective AVS (SS-AVS). We hereby present a case of aldosterone-producing adenoma (APA) diagnosed by SS-AVS and discuss the characteristics of difficult cases. Design and method: Case report: The 36-year-old patient with hypertension was treated with oral medication for five years, but the blood pressure control was poor. Endocrinological examinations were performed and it revealed low plasma renin activity (PRA 0.1 ng/ml/h) and high plasma aldosterone concentration (PAC 190 pg/ml). Imaging examinations showed a 13 mm-sized left adrenal mass. PA was suspected and AVS was performed subsequently to confirmation tests. However, aldosterone/cortisol ratios of both left and right adrenal central veins were lower than that of the inferior vena cava, and he failed to be diagnosed as APA. As we have employed SS-AVS since two years, we performed SS-AVS for the reevaluation for this case, and reviewed such undiagnosable cases. Results: A microcatheter was inserted to the tributaries of the left adrenal vein. Lateralized ratio (LR) using the aldosterone value in the tributary near the mass was 25.8 and contralateral ratio (CR) was 0.50. He was diagnosed as left APA and the surgery was performed. We diagnosed 30 APAs in total, but 8 cases failed to be diagnosed by conventional AVS. Among them, 7 cases were in the left side, and none of them were with tumor size larger than 15 mm. Conclusions: SS-AVS is useful for cases undiagnosable by conventinal AVS because a high plasma aldosterone level can be detected when a microcatheter is inserted closely to APA. It appears that such cases have much in common: a small mass in the left adrenal gland.

PS 17-08 CASES OF ALDOSTERONE-PRODUCING ADENOMAS WHICH WERE CURED BY RADIOFREQUENCY ABLATION: ONGOING CONFIRMATORY CLINICAL STUDY FOR EFFICACY AND SAFETY

Objective: A clinical study for the efficacy and safety for radiofrequency ablation (RFA) is ongoing in Japan. Design and method: Here we report 2 cases of aldosterone-producing adenomas (APA) in which RFA was performed. Results: Case 1: A forty-eight-year-old female was pointed out hypokalemia (2.8 mEq/l) by routine medical examination. Her blood pressure was 157/97 and the blood test showed low plasma renin activity (PRA, 0.2 ng/ml/hr) and high plasma aldosterone concentration (PAC, 476 pg/ml). Computed tomography (CT) scan showed 21mm-tumor in the right adrenal gland. Her captopril challenge test, furosemide upright test and oral sodium loading test were all positive and she was diagnosed a right aldosterone-producing adenoma (APA) by adrenal vein sampling (AVS). RFA treatment was performed on June 4th, 2015. She could stop amlodipine on the next day of the intervention and her PAC was normalized (44 pg/ml). Eight month after intervention, her blood pressure remained normal and her active renin concentration (ARC) and PAC also remained normal. Case 2: A thirty-five-year-old female visited an orthopedic hospital because of lower-extremity weakness. Her blood test showed hypokalemia (2.2 mEq/l) . She showed prehypertension (136/89) and the blood test showed low PRA (0.4ng/ml/hr) and high PAC (527 pg/ml). CT scan showed 16mm-tumor in the left adrenal gland. By the positivity of 3 loading tests and the result of AVS, she was diagnosed a left APA. RFA treatment was performed on July 2, 2015. Her PAC normalized (78 pg/ml) on the next day and she could stop spironolactone which was given mainly to control her hypokalemia. Two months later, she remained normokalemic and normotensive, and her ARC and PAC also remained normal. Conclusions: Both 2 cases were cured by RFA. Long-term follow-up should be needed to define efficacy.